A psychological disorder, is a psychological dysfunction within an individual associated with
distress or impairment in functioning and a response that is not typical or culturally expected.
Phobia, a psychological disorder characterized by marked and persistent fear of an object or
situation.
What Is a Psychological Disorder?
Psychological disorder: or problematic abnormal behavior: It is a psychological dysfunction
within an individual that is associated with distress or impairment in functioning and a response
that is not typical or culturally expected
Psychological dysfunction refers to a breakdown in cognitive, emotional, or behavioral
functioning.
Just having a dysfunction is not enough to meet the criteria for a psychological disorder.
That the behavior must be associated with distress to be classified as a disorder adds an
important component and seems clear: The criterion is satisfied if the individual is extremely
upset.
Distress or Impairment
It is often quite normal to be distressed—for example, if someone close to you dies. The human
condition is such that suffering and distress are very much part of life.
For some disorders, by definition, suffering and distress are absent.
Defining psychological disorder by distress alone doesn’t work, although the concept of distress
contributes to a good definition.
Distress - psychological suffering; extreme physical pain; a state of adversity (danger or
affliction or need.
Impairment - damage that results in a reduction of strength or quality; a symptom of reduced
quality or strength; the act of making something futile and useless (as by routine); the
occurrence of a change for the worse; the condition of being unable to perform as a
consequence of physical or mental.
The important point that most psychological disorders are simply extreme expressions of
otherwise normal emotions, behaviors, and cognitive processes.
The criterion that the response be atypical or not culturally expected is important but also
insufficient to determine if a disorder is present by itself.
Many people are far from the average in their behavior, but few would be considered
disordered. We might call them talented or eccentric.
“Deviating from the average” doesn’t work well as a definition for problematic abnormal
behavior.
Another view is that your behavior is disordered if you are violating social norms, even if a
number of people are sympathetic to your point of view. This definition is useful in considering
important cultural differences in psychological disorders. For example, to enter a trance state
and believe you are possessed reflects a psychological disorder in most Western cultures but
not in many other societies, where the behavior is accepted and expected.
Robert Sapolsky, the prominent neuroscientist who, during his studies, worked closely with the
Masai people in East Africa. One day, Sapolsky’s Masai friend Rhoda asked him to bring his
vehicle as quickly as possible to the Masai village where a woman had been acting aggressively
and had been hearing voices. The woman had actually killed a goat with her own hands.
Sapolsky and several Masai were able to subdue her and transport her to a local health center.
•Distress is normal in some situations
•Dysfunctional distress occurs when person is much more distressed than others would be
•Impairment: Must be spread throughout/pervasive and/or significant
•Mental disorders are often exaggerations of normal processes (e.g., extreme shyness or
sadness)
•Culture: Consider “normalcy” relative to behavior of others in same cultural context
•Rule of thumb: Mental disorder = harmful dysfunction
A social standard of normal has been misused, however. Consider, for example, the practice of
committing political dissidents to mental institutions because they protest the policies of their
government, which was common in Iraq before the fall of Saddam Hussein and now occurs in
Iran. Although such dissident behavior clearly violated social norms, it should not alone be
cause for commitment.
Jerome Wakefield (1999, 2009), in a thoughtful analysis of the matter, uses the shorthand
definition of harmful dysfunction. A related concept that is also useful is to determine whether
the behavior is out of the individual’s control (something the person doesn’t want to do)
(Widiger & Crego, 2013; Widiger & Sankis, 2000).
In conclusion, it is difficult to define what constitutes a psychological disorder —and the debate
continues. The most widely accepted definition used in the Diagnostic and Statistical Manual of
Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) describes
behavioral, psychological, or biological dysfunctions that are unexpected in their cultural
context and associated with present distress and impairment in functioning, or increased risk of
suffering, death, pain, or impairment.
The best we may be able to do is to consider how the apparent disease or disorder matches a
“typical” profile of a disorder—for example, major depression or schizophrenia—when most or
all symptoms that experts would agree are part of the disorder are present. We call this typical
profile a prototype.
We call this typical profile a prototype, and, as described in Chapter 3, the diagnostic criteria
from DSM-5 found throughout this book are all prototypes. This means that the patient may
have only some features or symptoms of the disorder (a minimum number) and still meet
criteria for the disorder because his or her set of symptoms is close to the prototype. But one of
the differences between DSM-5 and its predecessor, DSM-IV, is the addition of dimensional
estimates of the severity of specific disorders in DSM-5.
For the anxiety disorders, for example, the intensity and frequency of anxiety within a given
disorder such as panic disorder is rated on a 0 to 4 scale where a rating of 1 would indicate mild
or occasional symptoms and a rating of 4 would indicate continual and severe symptoms.
Psychopathology is the scientific study of psychological disorders.
Within this field are specially trained professionals, including clinical and counseling
psychologists, psychiatrists, psychiatric social workers, and psychiatric nurses, as well as
marriage and family therapists and mental health counselors.
Clinical psychologists and counseling psychologists receive the Ph.D., doctor of philosophy,
degree (or sometimes an Ed.D., doctor of education, or Psy.D., doctor of psychology) and follow
a course of graduate-level study lasting approximately 5 years, which prepares them to conduct
research into the causes and treatment of psychological disorders and to diagnose, assess, and
treat these disorders.
Although there is a great deal of overlap, counseling psychologists tend to study and treat
adjustment and vocational issues encountered by relatively healthy individuals, and clinical
psychologists usually concentrate on more severe psychological disorders.
Also, programs in professional schools of psychology, where the degree is often a Psy.D., focus
on clinical training and de-emphasize or eliminate research training. In contrast, Ph.D. programs
in universities integrate clinical and research training. Psychologists with other specialty
training, such as experimental and social psychologists, concentrate on investigating the basic
determinants of behavior but do not assess or treat psychological disorders.
Behavioral, psychological, or biological dysfunctions that are unexpected in their cultural
context and associated with present distress and/or impairment in functioning, or increased
risk of suffering, death, pain, or impairment.
Psychiatrists first earn an M.D. degree in medical school and then specialize in psychiatry during
residency training that lasts 3 to 4 years. Psychiatrists also investigate the nature and causes of
psychological disorders, often from a biological point of view; make diagnoses; and offer
treatments. Many psychiatrists emphasize drugs or other biological treatments, although most
use psychosocial treatments as well.
Psychiatric social workers typically earn a master’s degree in social work as they develop
expertise in collecting information relevant to the social and family situation of the individual
with a psychological disorder. Social workers also treat disorders, often concentrating on family
problems associated with them. Psychiatric nurses have advanced degrees, such as a master’s
or even a Ph.D., and specialize in the care and treatment of patients with psychological
disorders, usually in hospitals as part of a treatment team.
Marriage and family therapists and mental health counselors typically spend 1 to 2 years
earning a master’s degree and are employed to provide clinical services by hospitals or clinics,
usually under the supervision of a doctoral-level clinician.
The most important development in the recent history of psychopathology is the adoption of
scientific methods to learn more about the nature of psychological disorders, their causes, and
their treatment. Many mental health professionals take a scientific approach to their clinical
work and therefore are called scientist-practitioners
Mental health practitioners may function as scientist-practitioners in one or more of three ways
(see E Figure 1.2). First, they may keep up with the latest scientific developments in their field
and therefore use the most current diagnostic and treatment procedures. In this sense, they
are consumers of the science of psychopathology to the advantage of their patients. Second,
scientist-practitioners evaluate their own assessments or treatment procedures to see whether
they work. They are accountable not only to their patients but also to the government agencies
and insurance companies that pay for the treatments, so they must demonstrate clearly
whether their treatments are effective or not. Third, scientist-practitioners might conduct
research, often in clinics or hospitals, that produces new information about disorders or their
treatment, thus becoming immune to the fads that plague our field, often at the expense of
patients and their families. For example, new “miracle cures” for psychological disorders that
are reported several times a year in popular media would not be used by a scientist-practitioner
if there were no sound scientific data showing that they work. Such data flow from research
that attempts three basic things: to describe psychological disorders, to determine their causes,
and to treat them (see E Figure 1.3). These three categories compose an organizational
structure that recurs throughout this book and that is formally evident in the discussions of
specific disorders beginning in Chapter 5. A general overview of them now will give you a
clearer perspective on our efforts to understand abnormality.
Clinical Description
In hospitals and clinics, we often say that a patient “presents” with a specific problem or set of
problems or we discuss the presenting problem. Presents is a traditional shorthand way of
indicating why the person came to the clinic. Describing Judy’s presenting problem is the first
step in determining her clinical description, which represents the unique combination of
behaviors, thoughts, and feelings that make up a specific disorder. The word clinical refers both
to the types of problems or disorders that you would find in a clinic or hospital and to the
activities connected with assessment and treatment.
One important function of the clinical description is to specify what makes the disorder
different from normal behavior or from other disorders. Statistical data may also be relevant.
Prevalence - Number of people displaying a disorder in the total population at any given time
(compare with incidence).
Clinical description - details of the combination of behaviors, thoughts, and feelings of an
individual that make up a particular disorder.
Scientist-practitioners - Mental health professionals who are expected to apply scientific
methods to their work. They must keep current in the latest research on diagnosis and
treatment, they must evaluate their own methods for effectiveness, and they may generate
their own research to discover new knowledge of disorders and their treatment.
Psychological disorder - Psychological dysfunction associated with distress or impairment in
functioning that is not a typical or culturally expected response.
Phobia - Psychological disorder characterized by marked and persistent fear of an object or
situation.
Abnormal behavior - A psychological dysfunction within an individual that is associated with
distress or impairment in functioning and a response that is not typical or culturally expected.
Psychopathology - Scientific study of psychological disorders.
Presenting problem - Original complaint reported by the client to the therapist. The actual
treated problem may sometimes be a modification derived from the presenting problem.
Incidence - Number of new cases of a disorder appearing during a specific period (compare
with prevalence).
Course - Pattern of development and change of a disorder over time.
Prognosis - Predicted future development of a disorder over time.
Etiology - Cause or source of a disorder.
Exorcism - Religious ritual that attributes disordered behavior to possession by demons and
seeks to treat the individual by driving the demons from the body.
Psychosocial treatment - Treatment practices that focus on social and cultural factors (such as
family experience), as well as psychological influences. These approaches include cognitive,
behavioral, and interpersonal methods.
Moral therapy - Psychosocial approach in the 19th century that involved treating patients as
normally as possible in normal environments.
Mental hygiene movement - Mid-19th-century effort to improve care of the mentally
disordered by informing the public of their mistreatment.
Psychoanalysis - Psychoanalytic assessment and therapy, which emphasizes exploration of, and
insight into, unconscious processes and conflicts, pioneered by Sigmund Freud.
Behaviorism - Explanation of human behavior, including dysfunction, based on principles of
learning and adaptation derived from experimental psychology.
Unconscious - Part of the psychic makeup that is outside the awareness of the person.
Catharsis - Rapid or sudden release of emotional tension thought to be an important factor in
psychoanalytic therapy.
Psychoanalytic model - Complex and comprehensive theory originally advanced by Sigmund
Freud that seeks to account for the development and structure of personality, as well as the
origin of abnormal behavior, based primarily on inferred inner entities and forces.
id - In psychoanalysis, the unconscious psychical entity presents at birth representing basic
sexual and aggressive drives.
ego - In psychoanalysis, the psychical entity responsible for finding realistic and practical ways
to satisfy id drives.
Superego – In psychoanalysis, the psychical entity representing the internalized moral
principles of parents and society.
Intrapsychic conflicts - In psychoanalysis, the struggles among the id, ego, and superego.
Defense mechanisms - Common patterns of behavior, often adaptive coping styles when they
occur in moderation, observed in response to particular situations. In psychoanalysis, these are
thought to be unconscious processes originating in the ego.
Psychosexual stages of development - In psychoanalysis, the sequence of phases a person
passes through during development. Each stage is named for the location on the body where id
gratification is maximal at that time.
Castration anxiety In psychoanalysis, the fear in young boys that they will be mutilated
genitally because of their lust for their mothers.
Neurosis - Obsolete psychodynamic term for psychological disorder thought to result from
unconscious conflicts and the anxiety they cause. Plural is neuroses.
Ego psychology - Derived from psychoanalysis, this theory emphasizes the role of the ego in
development and attributes psychological disorders to failure of the ego to manage impulses
and internal conflicts. Also known as self-psychology.
Object relations - Modern development in psychodynamic theory involving the study of how
children incorporate the memories and values of people who are close and important to them.
Collective unconscious - Accumulated wisdom of a culture collected and remembered across
generations, a psychodynamic concept introduced by Carl Jung.
Free association - Psychoanalytic therapy technique intended to explore threatening material
repressed into the unconscious. The patient is instructed to say whatever comes to mind
without censoring.
Dream analysis - Psychoanalytic therapy method in which dream contents are examined as
symbolic of id impulses and intrapsychic conflicts.
Psychoanalyst - Therapist who practices psychoanalysis after earning either an M.D. or a Ph.D.
degree and receiving additional specialized postdoctoral training.
Transference - Psychoanalytic concept suggesting that clients may seek to relate to the
therapist as they do to important authority figures, particularly their parents.
Psychodynamic psychotherapy - Contemporary version of psychoanalysis that still emphasizes
unconscious processes and conflicts but is briefer and more focused on specific problems.
Self-actualizing - Process emphasized in humanistic psychology in which people strive to
achieve their highest potential against difficult life experiences.
Person-centered therapy - Therapy method in which the client, rather than the counselor,
primarily directs the course of discussion, seeking self-discovery and self-responsibility.
Unconditional positive regard - Acceptance by the counselor of the client’s feelings and actions
without judgment or condemnation.
Behavioral model - Explanation of human behavior, including dysfunction, based on principles
of learning and adaptation derived from experimental psychology.
Classical conditioning - Fundamental learning process first described by Ivan Pavlov. An event
that automatically elicits a response is paired with another stimulus event that does not (a
neutral stimulus). After repeated pairings, the neutral stimulus becomes a conditioned stimulus
that by itself can elicit the desired response.
Extinction - Learning process in which a response maintained by reinforcement in operant
conditioning or pairing in classical conditioning decreases when that reinforcement or pairing is
removed; also, the procedure of removing that reinforcement or pairing.
Introspection - Early, nonscientific approach to the study of psychology involving systematic
attempts to report thoughts and feelings that specific stimuli evoked.
Systematic desensitization - Behavioral therapy technique to diminish excessive fears, involving
gradual exposure to the feared stimulus paired with a positive coping experience, usually
relaxation.
Behavior therapy - Array of therapy methods based on the principles of behavioral and
cognitive science, as well as principles of learning as applied to clinical problems. It considers
specific behaviors rather than inferred conflicts as legitimate targets for change.
Reinforcement - In operant conditioning, consequences for behavior that strengthen it or
increase its frequency. Positive reinforcement involves the contingent delivery of a desired
consequence. Negative reinforcement is the contingent escape from an aversive consequence.
Unwanted behaviors may result from their reinforcement or the failure to reinforce desired
behaviors.
Shaping - In operant conditioning, the development of a new response by reinforcing
successively more similar versions of that response. Both desirable and undesirable behaviors
may be learned in this manner.
In addition to having different symptoms, age of onset, and possibly a different sex ratio and
prevalence, most disorders follow a somewhat individual pattern, or course.
For example, some disorders, such as schizophrenia follow a chronic course, meaning that they
tend to last a long time, sometimes a lifetime. Other disorders, like mood disorders, follow an
episodic course, in that the individual is likely to recover within a few months only to suffer a
recurrence of the disorder at a later time.
This pattern may repeat throughout a person’s life. Still other disorders may have a timelimited course, meaning the disorder will improve without treatment in a relatively short period
with little or no risk of recurrence.
Closely related to differences in course of disorders are differences in onset. Some disorders
have an acute onset, meaning that they begin suddenly;
Others develop gradually over an extended period, which is sometimes called an insidious
onset. It is important to know the typical course of a disorder so that we can know what to
expect in the future and how best to deal with the problem.
The earliest explanations for psychological disorders were based on religious and supernatural
beliefs. For example, many believed that abnormal behavior was due to possession by demons or
evil spirits. Hippocrates was one of the first to consider the role of biology in causing
psychological disorders.
Alison is expressing a supernatural view because evil spirits refers to something outside or
beyond the natural world. Common treatments adopted by those who believe in supernatural
explanations for abnormal behavior include exorcism and prayer.
All of these individuals are known for their work to reform asylums by providing more humane
and therapeutic treatment of patients. Before the reform efforts of individuals such as these, the
earliest asylums functioned more as prisons than hospitals or treatment centers.
Albert is expressing a humoral view because bloodletting and induced vomiting were treatments
used to attempt to bring the four humors back in balance. This view originated with Hippocrates
and the ancient Greeks and is perhaps the first example of associating psychological disorders
with a chemical imbalance in the body.
In the client-centered approach, the client largely dictates the direction and pace of treatment.
The therapist establishes a supportive environment, allows clients to determine what topics are
broached and into how much depth or detail the therapy goes, and encourages them to express
themselves without worrying about being judged. The humanistic framework of this approach
states that the primary benefit for the client is the ability to conduct self-examination and develop
a self-image that is rooted in reality.
Since the psychoanalytic and humanistic traditions emphasize concepts and variables that are
difficult to observe and measure, they are viewed as less scientific than the behavioral model.
Classical conditioning is a form of associative learning. A neutral stimulus is paired with an
unconditioned stimulus, which is something that naturally elicits a response. Eventually, the
person being conditioned learns the association between the stimuli, and the formerly neutral
stimulus begins to elicit a response. The intensity of the response elicited by the unconditioned
stimulus can impact how quickly this association is made. For example, if you eat lasagna and
get violently ill, you may have a strong reaction of nausea the next time you're around it. If you
get mildly ill, the reaction might not be so severe, and you might be willing to give it another try.
If you continue to get sick whenever you eat it, however, your reaction will probably get more
severe. You may even generalize to similar foods and feel nauseated around other types of pasta
or Italian food.
Watson's work with Albert, an 11-month-old infant, demonstrated that fear responses could be
elicited through conditioning and that these responses generalized to a range of stimuli. This
provided a plausible mechanism for explaining how phobias and some anxiety disorders might
develop. Patients associate a stimulus with a highly negative outcome, producing fear. This
discovery was expanded by Mary Cover Jones, who applied the principle of extinction to the
treatment of fear. Gradual exposure to fearful stimuli, accompanied by reassurance and a safe
environment, produced a gradual lessening of the fear. The association between the stimulus and
the expected negative outcome gets broken, eliminating the fear.
Operant conditioning is based on learning associations between actions and consequences. If
something positive happens, an action is likely to be repeated. If something negative happens,
the frequency of the action decreases. This differs from classical conditioning, which focuses on
the response elicited by forming an association between two types of stimuli. In Skinner's view,
reinforcement was a more powerful motivator than punishment. The desire for something good
to happen is stronger than the fear of something bad happening. In the case of psychological
disorders, a strict behaviorist would say that the primary issue is the behavior being displayed
and treatment should focus on altering it. This emphasis, however, means that such a model is
unable to account for all of the factors that contribute to a psychological disorder.
3 . Behavioral model
Based on principles of learning and conditioning, the behavioral model has had an important and
lasting impact on our understanding of psychopathology. It is generally considered more
scientific than the psychoanalytic and humanistic traditions.
Points:
1/1
Close Explanation
Explanation:
Since the psychoanalytic and humanistic traditions emphasize concepts and variables that are
difficult to observe and measure, they are viewed as less scientific than the behavioral model.
Classical conditioning is classified as a form of associative learning. Which of the following
factors can increase the speed with which a stimulus-response association can be learned?
Using an unconditioned stimulus that elicits a more intense response
Repeatedly presenting the neutral stimulus by itself, without the unconditioned stimulus
Presenting numerous neutral stimuli before the response is elicited
Points:
1/1
Close Explanation
Explanation:
Classical conditioning is a form of associative learning. A neutral stimulus is paired with an
unconditioned stimulus, which is something that naturally elicits a response. Eventually, the
person being conditioned learns the association between the stimuli, and the formerly neutral
stimulus begins to elicit a response. The intensity of the response elicited by the unconditioned
stimulus can impact how quickly this association is made. For example, if you eat lasagna and
get violently ill, you may have a strong reaction of nausea the next time you're around it. If you
get mildly ill, the reaction might not be so severe, and you might be willing to give it another try.
If you continue to get sick whenever you eat it, however, your reaction will probably get more
severe. You may even generalize to similar foods and feel nauseated around other types of pasta
or Italian food.
The behavioral approach to psychological disorders currently encompasses a wide range of
theories based on principles that underlie different forms of learning. Initially, classical
conditioning served as the basis of the behavioral perspective. John Watson was one of the first
researchers to examine this connection. One of the primary behavioral methods of treating
phobias is systematic desensitization, which relies heavily on the principle of extinction. What
happens in this type of treatment?
Patients are gradually exposed to increasingly intense versions of items that elicit fear.
Patients are unexpectedly exposed to a highly intense fearful situation, while the therapist
provides verbal assurances that they are safe.
Items that elicit fear responses in patients are paired with items that elicit pleasurable responses
until new associations are formed.
Points:
0/1
Close Explanation
Explanation:
Watson's work with Albert, an 11-month-old infant, demonstrated that fear responses could be
elicited through conditioning and that these responses generalized to a range of stimuli. This
provided a plausible mechanism for explaining how phobias and some anxiety disorders might
develop. Patients associate a stimulus with a highly negative outcome, producing fear. This
discovery was expanded by Mary Cover Jones, who applied the principle of extinction to the
treatment of fear. Gradual exposure to fearful stimuli, accompanied by reassurance and a safe
environment, produced a gradual lessening of the fear. The association between the stimulus and
the expected negative outcome gets broken, eliminating the fear.
Skinner never focused particularly on psychological disorders, but the principles of operant
conditioning have been applied to explain how psychological disorders can develop. Which of
the following descriptions of psychological treatment is most consistent with Skinner's view of
operant conditioning?
A patient suffering from social anxiety rewards himself after overcoming his fear and
successfully asking a stranger, “Can you tell me the time?”
A therapist attempts to use dream analysis to determine the underlying reasons for a patient's
marital difficulties.
A patient suffering from depression attempts to purge negative thoughts by reinterpreting them
and changing her view.
Points:
1/1
Close Explanation
Explanation:
Operant conditioning is based on learning associations between actions and consequences. If
something positive happens, an action is likely to be repeated. If something negative happens,
the frequency of the action decreases. This differs from classical conditioning, which focuses on
the response elicited by forming an association between two types of stimuli. In Skinner's view,
reinforcement was a more powerful motivator than punishment. The desire for something good
to happen is stronger than the fear of something bad happening. In the case of psychological
disorders, a strict behaviorist would say that the primary issue is the behavior being displayed
and treatment should focus on altering it. This emphasis, however, means that such a model is
unable to account for all of the factors that contribute to a psychological disorder.
Read the scenario and answer the questions that follow.
Janis's parents are upset that she never does her household chores. With the help of a behavioral
therapist, the parents develop a system whereby Janis earns tickets for doing various chores. At
the end of the week, Janis can exchange the tickets for things such as more allowance, a later
curfew, and other desired objects or activities.
The plan Janis's parents are using to improve her completion of household chores is based on
what?
Operant conditioning
Classical conditioning
Unconditional positive regard
Extinction
Points:
1/1
Close Explanation
Explanation:
This plan is based on operant conditioning because Janis's parents are changing the consequences
of her behavior in order to change the behavior. They are attempting to reinforce Janis's behavior
of completing household chores by providing her with tickets that can be exchanged for desirable
things. This type of treatment is known as a token economy, whereby tokens (such as tickets)
that are exchangeable for reinforcers are delivered as a consequence for desirable behaviors.
Classical conditioning involves pairing a neutral stimulus with a response until it elicits that
response itself. Extinction is the process in classical conditioning whereby the conditioned
stimulus is repeatedly presented without the unconditioned stimulus until the conditioned
stimulus no longer elicits the conditioned response. Unconditional positive regard is a concept
from humanistic psychology.
The Psychological Tradition
It is a long leap from evil spirits to brain pathology as the cause of psychological disorders. In the
intervening centuries, where was the body of thought that put psychological development, both normal
and abnormal, in an interpersonal and social context? In fact, this approach has a long and distinguished
tradition. Plato, for example, thought that the two causes of maladaptive behavior were the social and
cultural influences in one’s life and the learning that took place in that environment. If something was
wrong in the environment, such as abusive parents, one’s impulses and emotions would overcome
reason. The best treatment was to reeducate the individual through rational discussion so that the
power of reason would predominate (Maher & Maher, 1985a). This was very much a precursor to
modern psychosocial treatment approaches to the causation of psychopathology, which focus not only
on psychological factors but also on social and cultural ones. Other well-known early philosophers,
including Aristotle, also emphasized the influence of social environment and early learning on later
psychopathology. These philosophers wrote about the importance of fantasies, dreams, and cognitions
and thus anticipated, to some extent, later developments in psychoanalytic thought and cognitive
science. They also advocated humane and responsible care for individuals with psychological
disturbances.
Moral Therapy
During the first half of the 19th century, a strong psychosocial approach to mental disorders called
moral therapy became influential. The term moral actually referred more to emotional or psychological
factors rather than to a code of conduct. Its basic tenets included treating institutionalized patients as
normally as possible in a setting that encouraged and reinforced normal social interaction (Bockoven,
1963), thus providing them with many opportunities for appropriate social and interpersonal contact.
Relationships were carefully nurtured. Individual attention clearly emphasized positive consequences for
appropriate interactions and behavior, and restraint and seclusion were eliminated.
As with the biological tradition, the principles of moral therapy date back to Plato and beyond. For
example, the Greek Asclepiad Temples of the 6th century housed the chronically ill, including those with
psychological disorders. Here, patients were well cared for, massaged, and provided with soothing
music. Similar enlightened practices were evident in Muslim countries in the Middle East (Millon, 2004).
But moral therapy as a system originated with the well-known French psychiatrist Philippe Pinel (1745–
1826) and his close associate Jean-Baptiste Pussin (1746–1811), who was the superintendent of the
Parisian hospital La Bicêtre (Gerard, 1997; Zilboorg & Henry, 1941).
When Pinel arrived in 1791, Pussin had already instituted remarkable reforms by removing all chains
used to restrain patients and instituting humane and positive psychological interventions. Pussin
persuaded Pinel to go along with the changes. Much to Pinel’s credit, he did, first at La Bicêtre and then
at the women’s hospital Salpétrière, where he invited Pussin to join him (Gerard, 1997; Maher & Maher,
1985b; Weiner, 1979). Here again, they instituted a humane and socially facilitative atmosphere that
produced “miraculous” results.
After William Tuke (1732–1822) followed Pinel’s lead in England, Benjamin Rush (1745–1813), often
considered the founder of U.S. psychiatry, introduced moral therapy in his early work at Pennsylvania
Hospital. It then became the treatment of choice in the leading hospitals. Asylums had appeared in the
16th century, but they were more like prisons than hospitals. It was the rise of moral therapy in Europe
and the United States that made asylums habitable and even therapeutic.
In 1833, Horace Mann, chairman of the board of trustees of the Worcester State Hospital, reported on
32 patients who had been given up as incurable. These patients were treated with moral therapy, cured,
and released to their families. Of 100 patients who were viciously assaultive before treatment, no more
than 12 continued to be violent a year after beginning treatment. Before treatment, 40 patients had
routinely torn off any new clothes provided by attendants; only 8 continued this behavior after a period
of treatment. These were remarkable statistics then and would be remarkable even today (Bockoven,
1963).
Asylum Reform and the Decline of Moral Therapy
Unfortunately, after the mid-19th century, humane treatment declined because of a convergence of
factors. First, it was widely recognized that moral therapy worked best when the number of patients in
an institution was 200 or fewer, allowing for a great deal of individual attention. After the Civil War,
enormous waves of immigrants arrived in the United States, yielding their own populations of mentally
ill. Patient loads in existing hospitals increased to 1,000 or 2,000, and even more. Because immigrant
groups were thought not to deserve the same privileges as “native” Americans (whose ancestors had
immigrated perhaps only 50 or 100 years earlier!), they were not given moral treatments even when
there were sufficient hospital personnel.
A second reason for the decline of moral therapy has an unlikely source. The great crusader Dorothea
Dix (1802–1887) campaigned endlessly for reform in the treatment of insanity. A schoolteacher who had
worked in various institutions, she had firsthand knowledge of the deplorable conditions imposed on
patients with insanity, and she made it her life’s work to inform the American public and their leaders of
these abuses. Her work became known as the mental hygiene movement.
In addition to improving the standards of care, Dix worked hard to make sure that everyone who needed
care received it, including the homeless. Through her efforts, humane treatment became more widely
available in U.S. institutions. As her career drew to a close, she was rightly acknowledged as a hero of
the 19th century.
Asylums and Poor Farms in Rural America
In 1822 at an annual town meeting, the town of Nantucket, a small island 30 miles off the coast of
Massachusetts, voted to build a permanent town poor farm and asylum (Gavin, 2003). After the War of
1812, Nantucket had prospered from trade as well as from the beginning of the great whaling era and
the citizens wanted to take care of the less fortunate. Inspired by more modern beliefs at the time about
the treatment of insanity, it was decided to place the asylum away from town in an area where
residents could work productively in a pleasant and restful rural setting with fresh air, individual
attention, and the availability of productive activities. As was characteristic of those days, asylums also
cared for the poor and the elderly.
Since misuse of alcohol was considered the principal cause of poverty, moving the asylums as far away
from taverns as possible seemed logical and was another reason for locating the asylum in the country.
But more importantly, both alcohol abuse and insanity were considered curable after word reached the
island of the very positive results from moral therapy at McLean Asylum near Boston. Thus, it was
arranged for residents of the asylum to engage principally in agricultural labor, producing vegetables,
eggs, and dairy products or working outside in the wheat and rye fields or with the livestock. The elderly
or those unable to work outside of the asylum were provided with productive work in their room such
as weaving. Consistent with the tenets of moral therapy, it was thought that a majority of the inmates
might recover under the benefits of this healthy and restorative atmosphere. And the poor farm was
well run and profitable for the town!
After building the asylum, town officials appointed a Board of Overseers, responsible leaders of
Nantucket, who immediately became concerned about the number of people visiting the asylum and
poor farm presumably to gawk at the insane. In a further effort to protect the residents, the town
passed an ordinance restricting visits only to those who applied in writing and offered a good reason for
visiting. Unfortunately, in the winter of February 1844, the structure burned to the ground. Despite
heroic efforts of many townspeople, ten inmates were killed and the structure was destroyed.
Eventually a new asylum was built, but by this time it housed only the sick and elderly who could no
longer care for themselves. By that time, the new state asylum for the insane had opened far from the
island and the removal of people suffering from insanity to this large (and impersonal) state institution
was seen as desirable. New policies were adopted for cases of poverty (presumably those not suffering
from addiction of some kind) that included maintaining the poor in their dwellings and providing them
with sufficient (but minimal) materials and resources to see them through. A new town “poor
department” was created for this purpose. Thus did moral therapy rise and fall in a small rural town in
New England, reflecting the tenor of the time (Gavin, 2003).
Dorothea Dix (1802–1887) began the mental hygiene movement and spent much of her life campaigning
for reform in the treatment of the mentally ill.
Dorothea Dix (1802–1887) began the mental hygiene movement and spent much of her life campaigning
for reform in the treatment of the mentally ill.
Unfortunately, an unforeseen consequence of Dix’s heroic efforts was a substantial increase in the
number of mental patients. This influx led to a rapid transition from moral therapy to custodial care
because hospitals were inadequately staffed. Dix reformed our asylums and single-handedly inspired the
construction of numerous new institutions here and abroad. But even her tireless efforts and advocacy
could not ensure sufficient staffing to allow the individual attention necessary to moral therapy. A final
blow to the practice of moral therapy was the decision, in the middle of the 19th century, that mental
illness was caused by brain pathology and, therefore, was incurable.
The psychological tradition lay dormant for a time, only to reemerge in several different schools of
thought in the 20th century. The first major approach was psychoanalysis, based on Sigmund Freud’s
(1856–1939) elaborate theory of the structure of the mind and the role of unconscious processes in
determining behavior. The second was behaviorism, associated with John B. Watson, Ivan Pavlov, and B.
F. Skinner, which focuses on how learning and adaptation affect the development of psychopathology.
Psychoanalytic Theory
Have you ever felt as if someone cast a spell on you? Have you ever been mesmerized by a look across
the classroom from a beautiful man or woman, or a stare from a rock musician as you sat down in front
at a concert? If so, you have something in common with the patients of Franz Anton Mesmer (1734–
1815) and with millions of people since his time who have been hypnotized. Mesmer suggested to his
patients that their problem was caused by an undetectable fluid found in all living organisms called
“animal magnetism,” which could become blocked.
Mesmer had his patients sit in a dark room around a large vat of chemicals with rods extending from it
and touching them. Dressed in flowing robes, he might then identify and tap various areas of their
bodies where their animal magnetism was blocked while suggesting strongly that they were being
cured. Because of his rather unusual techniques, Mesmer was considered an oddity and maybe a
charlatan, strongly opposed by the medical establishment (Winter, 1998). In fact, none less than
Benjamin Franklin put animal magnetism to the test by conducting a brilliant experiment in which
patients received either magnetized water or nonmagnetized water with strong suggestions that they
would get better. Neither the patient nor the therapist knew which water was which, making it a
double-blind experiment (see Chapter 4). When both groups got better, Franklin concluded that animal
magnetism, or mesmerism, was nothing more than strong suggestion (Gould, 1991; McNally, 1999).
Nevertheless, Mesmer is widely regarded as the father of hypnosis, a state in which extremely
suggestible subjects sometimes appear to be in a trance.
Many distinguished scientists and physicians were interested in Mesmer’s powerful methods of
suggestion. One of the best known, Jean-Martin Charcot (1825–1893), was head of the Salpétrière
Hospital in Paris, where Philippe Pinel had introduced psychological treatments several generations
earlier. A distinguished neurologist, Charcot demonstrated that some techniques of mesmerism were
effective with a number of psychological disorders, and he did much to legitimize the fledgling practice
of hypnosis. Significantly, in 1885 a young man named Sigmund Freud came from Vienna to study with
Charcot.
After returning from France, Freud teamed up with Josef Breuer (1842–1925), who had experimented
with a somewhat different hypnotic procedure. While his patients were in the highly suggestible state of
hypnosis, Breuer asked them to describe their problems, conflicts, and fears in as much detail as they
could. Breuer observed two extremely important phenomena during this process. First, patients often
became extremely emotional as they talked and felt quite relieved and improved after emerging from
the hypnotic state. Second, seldom would they have gained an understanding of the relationship
between their emotional problems and their psychological disorder. In fact, it was difficult or impossible
for them to recall some details they had described under hypnosis. In other words, the material seemed
to be beyond the awareness of the patient. With this observation, Breuer and Freud had “discovered”
the unconscious mind and its apparent influence on the production of psychological disorders. This is
one of the most important developments in the history of psychopathology and, indeed, of psychology
as a whole.
A close second was their discovery that it is therapeutic to recall and relive emotional trauma that has
been made unconscious and to release the accompanying tension. This release of emotional material
became known as catharsis. A fuller understanding of the relationship between current emotions and
earlier events is referred to as insight. As you shall see throughout this book, particularly in Chapters 5
and Chapters 6 on anxiety and somatic symptom disorders, the existence of “unconscious” memories
and feelings and the importance of processing emotion-filled information have been verified and
reaffirmed.
Franz Anton Mesmer (1734–1815) and other early therapists often used hypnosis and/or strong
suggestions to cure their patients.
Freud and Breuer’s theories were based on case observations, some of which were made in a
surprisingly systematic way for those times. An excellent example is Breuer’s classic description of his
treatment of “hysterical” symptoms in Anna O. in 1895 (Breuer & Freud, 1895/ 1957). Anna O. was a
bright, attractive young woman who was perfectly healthy until she reached 21 years of age. Shortly
before her problems began, her father developed a serious chronic illness that led to his death.
Throughout his illness, Anna O. had cared for him; she felt it necessary to spend endless hours at his
bedside. Five months after her father became ill, Anna noticed that during the day her vision blurred
and that from time to time she had difficulty moving her right arm and both legs. Soon, additional
symptoms appeared. She began to experience some difficulty speaking, and her behavior became
unpredictable. Shortly thereafter, she consulted Breuer.
Jean Charcot (1825–1893) studied hypnosis and influenced Sigmund Freud to consider psychosocial
approaches to psychological disorders.
Josef Breuer (1842–1925) worked on the celebrated case of Anna O. and, with Sigmund Freud,
developed the theory of psychoanalysis.
In a series of treatment sessions, Breuer dealt with one symptom at a time through hypnosis and
subsequent “talking through,” tracing each symptom to its hypothetical causation in circumstances
surrounding the death of Anna’s father. One at a time, her “hysterical” ailments disappeared, but only
after treatment was administered for each respective behavior. This process of treating one behavior at
a time fulfills a basic requirement for drawing scientific conclusions about the effects of treatment in an
individual case study, as you will see in Chapter 4. We will return to the fascinating case of Anna O. in
Chapter 6.
Freud took these basic observations and expanded them into the psychoanalytic model, the most
comprehensive theory yet constructed on the development and structure of our personalities. He also
speculated on where this development could go wrong and produce psychological disorders. Although
many of Freud’s views changed over time, the basic principles of mental functioning that he originally
proposed remained constant through his writings and are still applied by psychoanalysts today.
Although most of it remains unproven, psychoanalytic theory has had a strong influence, and it is still
important to be familiar with its basic ideas; what follows is a brief outline of the theory. We focus on its
three major facets:
the structure of the mind and the distinct functions of personality that sometimes clash with one
another;
The defense mechanisms with which the mind defends itself from these clashes, or conflicts; and
The stages of early psychosexual development that provide grist for the mill of our inner conflicts.
The Structure of the Mind
The mind, according to Freud, has three major parts or functions: the id, the ego, and the superego (see
Figure 1.4). These terms, like many from psychoanalysis, have found their way into our common
vocabulary, but although you may have heard them, you may not be aware of their meaning. The id is
the source of our strong sexual and aggressive feelings or energies. It is, basically, the animal within us; if
totally unchecked, it would make us all rapists or killers. The energy or drive within the id is the libido.
Even today, some people explain low sex drive as an absence of libido. A less important source of
energy, not as well conceptualized by Freud, is the death instinct, or thanatos. These two basic drives,
toward life and fulfillment on the one hand and death and destruction on the other, are continually in
opposition.
Freud’s structure of the mind.
Bertha Pappenheim (1859–1936), famous as Anna O., was described as “hysterical” by Breuer.
The id operates according to the pleasure principle, with an overriding goal of maximizing pleasure and
eliminating any associated tension or conflicts. The goal of pleasure, which is particularly prominent in
childhood, often conflicts with social rules and regulations, as you shall see later. The id has its own
characteristic way of processing information; referred to as the primary process, this type of thinking is
emotional, irrational, illogical, filled with fantasies, and preoccupied with sex, aggression, selfishness,
and envy.
Fortunately for all of us, in Freud’s view, the id’s selfish and sometimes dangerous drives do not go
unchecked. In fact, only a few months into life, we know we must adapt our basic demands to the real
world. In other words, we must find ways to meet our basic needs without offending everyone around
us. Put yet another way, we must act realistically. The part of our mind that ensures that we act
realistically is called the ego, and it operates according to the reality principle instead of the pleasure
principle. The cognitive operations or thinking styles of the ego are characterized by logic and reason
and are referred to as the secondary process, as opposed to the illogical and irrational primary process
of the id.
The third important structure within the mind, the superego, or what we might call conscience,
represents the moral principles instilled in us by our parents and our culture. It is the voice within us
that nags at us when we know we’re doing something wrong. Because the purpose of the superego is to
counteract the potentially dangerous aggressive and sexual drives of the id, the basis for conflict is
readily apparent.
Sigmund Freud (1856–1939) is considered the founder of psychoanalysis.
The role of the ego is to mediate conflict between the id and the superego, juggling their demands with
the realities of the world. The ego is often referred to as the executive or manager of our minds. If it
mediates successfully, we can go on to the higher intellectual and creative pursuits of life. If it is
unsuccessful and the id or superego becomes too strong, conflict will overtake us and psychological
disorders will develop. Because these conflicts are all within the mind, they are referred to as
intrapsychic conflicts. Now think back to the case of Anna O., in which Breuer observed that patients
cannot always remember important but unpleasant emotional events. From these and other
observations, Freud conceptualized the mental structures described in this section to explain
unconscious processes. He believed that the id and the superego are almost entirely unconscious. We
are fully aware only of the secondary processes of the ego, which is a relatively small part of the mind.
Defense Mechanisms
The ego fights a continual battle to stay on top of the warring id and superego. Occasionally, their
conflicts produce anxiety that threatens to overwhelm the ego. The anxiety is a signal that alerts the ego
to marshal defense mechanisms, unconscious protective processes that keep primitive emotions
associated with conflicts in check so that the ego can continue its coordinating function. Although Freud
first conceptualized defense mechanisms, it was his daughter, Anna Freud, who developed the ideas
more fully.
We all use defense mechanisms at times—they are sometimes adaptive and at other times maladaptive.
For example, have you ever done poorly on a test because the professor was unfair in the grading? And
then when you got home you yelled at your younger brother or perhaps even your dog? This is an
example of the defense mechanism of displacement. The ego adaptively decides that expressing
primitive anger at your professor might not be in your best interest. Because your brother and your dog
don’t have the authority to affect you in an adverse way, your anger is displaced to one of them. Some
people may redirect energy from conflict or underlying anxiety into a more constructive outlet such as
work, where they may be more efficient because of the redirection. This process is called sublimation.
More severe internal conflicts that produce a lot of anxiety or other emotions can trigger self-defeating
defensive processes or symptoms. Phobic and obsessive symptoms are especially common selfdefeating defensive reactions that, according to Freud, reflect an inadequate attempt to deal with an
internally dangerous situation. Phobic symptoms typically incorporate elements of the danger. For
example, a dog phobia may be connected to an infantile fear of castration; that is, a man’s internal
conflict involves a fear of being attacked and castrated, a fear that is consciously expressed as a fear of
being attacked and bitten by a dog, even if he knows the dog is harmless.
Defense mechanisms have been subjected to scientific study, and there is some evidence that they may
be of potential import in the study of psychopathology (Vaillant, 1992; 2012). For example, Perry and
Bond (2012, 2014) noted that reduction in unadaptive defense mechanisms, and strengthening of
adaptive mechanisms such as humor and sublimation, correlated with psychological health. Thus, the
concept of defense mechanisms—coping styles, in contemporary terminology—continues to be
important to the study of psychopathology.
Denial: Refuses to acknowledge some aspect of objective reality or subjective experience that is
apparent to others
Displacement: Transfers a feeling about, or a response to, an object that causes discomfort onto
another, usually less-threatening, object or person
Projection: Falsely attributes own unacceptable feelings, impulses, or thoughts to another individual or
object
Rationalization: Conceals the true motivations for actions, thoughts, or feelings through elaborate
reassuring or self-serving but incorrect explanations
Reaction formation: Substitutes behavior, thoughts, or feelings that are the direct opposite of
unacceptable ones
Repression: Blocks disturbing wishes, thoughts, or experiences from conscious awareness
Sublimation: Directs potentially maladaptive feelings or impulses into socially acceptable behavior
Psychosexual Stages of Development
Freud also theorized that during infancy and early childhood we pass through a number of psychosexual
stages of development that have a profound and lasting impact. This makes Freud one of the first to
take a developmental perspective on the study of abnormal behavior, which we look at in detail
throughout this book. The stages—oral, anal, phallic, latency, and genital—represent distinctive patterns
of gratifying our basic needs and satisfying our drive for physical pleasure. For example, the oral stage,
typically extending for approximately 2 years from birth, is characterized by a central focus on the need
for food. In the act of sucking, necessary for feeding, the lips, tongue, and mouth become the focus of
libidinal drives and, therefore, the principal source of pleasure. Freud hypothesized that if we did not
receive appropriate gratification during a specific stage or if a specific stage left a particularly strong
impression (which he termed fixation), an individual’s personality would reflect the stage throughout
adult life. For example, fixation at the oral stage might result in excessive thumb sucking and emphasis
on oral stimulation through eating, chewing pencils, or biting fingernails. Adult personality
characteristics theoretically associated with oral fixation include dependency and passivity or, in
reaction to these tendencies, rebelliousness and cynicism.
One of the more controversial and frequently mentioned psychosexual conflicts occurs during the
phallic stage (from age 3 to age 5 or 6), which is characterized by early genital self-stimulation.
This conflict is the subject of the Greek tragedy Oedipus Rex, in which Oedipus is fated to kill his father
and, unknowingly, to marry his mother. Freud asserted that all young boys relive this fantasy when
genital self-stimulation is accompanied by images of sexual interactions with their mothers. These
fantasies, in turn, are accompanied by strong feelings of envy and perhaps anger toward their fathers,
with whom they identify but whose place they wish to take. Furthermore, strong fears develop that the
father may punish that lust by removing the son’s penis—thus, the phenomenon of castration anxiety.
This fear helps the boy keep his lustful impulses toward his mother in check. The battle of the lustful
impulses on the one hand and castration anxiety on the other creates a conflict that is internal, or
intrapsychic, called the Oedipus complex. The phallic stage passes uneventfully only if several things
happen. First, the child must resolve his ambivalent relationship with his parents and reconcile the
simultaneous anger and love he has for his father. If this happens, he may go on to channel his libidinal
impulses into heterosexual relationships while retaining harmless affection for his mother.
The counterpart conflict in girls, called the Electra complex, is even more controversial. Freud viewed
the young girl as wanting to replace her mother and possess her father. Central to this possession is the
girl’s desire for a penis, so as to be more like her father and brothers—hence the term penis envy.
According to Freud, the conflict is successfully resolved when females develop healthy heterosexual
relationships and look forward to having a baby, which he viewed as a healthy substitute for having a
penis. Needless to say, this particular theory has provoked marked consternation over the years as being
sexist and demeaning. It is important to remember that it is theory, not fact; no systematic research
exists to support it.
Anna Freud (1895–1982), here with her father, contributed the concept of defense mechanisms to the
field of psychoanalysis.
In Freud’s view, all nonpsychotic psychological disorders resulted from underlying unconscious conflicts,
the anxiety that resulted from those conflicts, and the implementation of ego defense mechanisms.
Freud called such disorders neuroses, or neurotic disorders, from an old term referring to disorders of
the nervous system.
Later Developments in Psychoanalytic Thought
Freud’s original psychoanalytic theories have been greatly modified and developed in a number of
different directions, mostly by his students or followers. Some theorists simply took one component of
psychoanalytic theory and developed it more fully. Others broke with Freud and went in entirely new
directions.
Anna Freud (1895–1982), Freud’s daughter, concentrated on the way in which the defensive reactions of
the ego determine our behavior. In so doing, she was the first proponent of the modern field of ego
psychology. Her book Ego and the Mechanisms of Defense (1946) is still influential. According to Anna
Freud, the individual slowly accumulates adaptational capacities, skill in reality testing, and defenses.
Abnormal behavior develops when the ego is deficient in regulating such functions as delaying and
controlling impulses or in marshaling appropriate normal defenses to strong internal conflicts. In
another somewhat later modification of Freud’s theories, Heinz Kohut (1913–1981) focused on a theory
of the formation of self-concept and the crucial attributes of the self that allow an individual to progress
toward health, or conversely, to develop neurosis. This psychoanalytic approach became known as selfpsychology (Kohut, 1977).
A related area that is quite popular today is referred to as object relations. Object relations is the study
of how children incorporate the images, the memories, and sometimes the values of a person who was
important to them and to whom they were (or are) emotionally attached. Object in this sense refers to
these important people, and the process of incorporation is called introjection. Introjected objects can
become an integrated part of the ego or may assume conflicting roles in determining the identity, or
self. For example, your parents may have conflicting views on relationships or careers, which, in turn,
may be different from your own point of view. To the extent that these varying positions have been
incorporated, the potential for conflict arises. One day you may feel one way about your career
direction, and the next day you may feel quite differently.
According to object relations theory, you tend to see the world through the eyes of the person
incorporated into your self. Object relations theorists focus on how these disparate images come
together to make up a person’s identity and on the conflicts that may emerge.
Carl Jung (1875–1961) and Alfred Adler (1870–1937) were students of Freud who came to reject his
ideas and form their own schools of thought. Jung, rejecting many of the sexual aspects of Freud’s
theory, introduced the concept of the collectiveunconscious, which is a wisdom accumulated by society
and culture that is stored deep in individual memories and passed down from generation to generation.
Jung also suggested that spiritual and religious drives are as much a part of human nature as are sexual
drives; this emphasis and the idea of the collective unconscious continue to draw the attention of
mystics. Jung emphasized the importance of enduring personality traits such as introversion (the
tendency to be shy and withdrawn) and extroversion (the tendency to be friendly and outgoing).
Adler focused on feelings of inferiority and the striving for superiority; he created the term inferiority
complex. Unlike Freud, both Jung and Adler also believed that the basic quality of human nature is
positive and that there is a strong drive toward self-actualization (realizing one’s full potential). Jung and
Adler believed that by removing barriers to both internal and external growth the individual would
improve and flourish.
Others took psychoanalytical theorizing in different directions, emphasizing development over the life
span and the influence of culture and society on personality. Karen Horney (1885–1952) and Erich
Fromm (1900–1980) are associated with these ideas, but the best-known theorist is Erik Erikson (1902–
1994). Erikson’s greatest contribution was his theory of development across the life span, in which he
described in some detail the crises and conflicts that accompany eight specific stages. For example, in
the last of these stages, the mature age, beginning about age 65, individuals review their lives and
attempt to make sense of them, experiencing both satisfaction at having completed some lifelong goals
and despair at having failed at others. Scientific developments have borne out the wisdom of
considering psychopathology from a developmental point of view.
Psychoanalytic Psychotherapy
Many techniques of psychoanalytic psychotherapy, or psychoanalysis, are designed to reveal the nature
of unconscious mental processes and conflicts through catharsis and insight. Freud developed
techniques of free association, in which patients are instructed to say whatever comes to mind without
the usual socially required censoring. Free association is intended to reveal emotionally charged
material that may be repressed because it is too painful or threatening to bring into consciousness.
Freud’s patients lay on a couch, and he sat behind them so that they would not be distracted. This is
how the couch became the symbol of psychotherapy. Other techniques include dream analysis (still
quite popular today), in which the therapist interprets the content of dreams, supposedly reflecting the
primary-process thinking of the id, and systematically relates the dreams to symbolic aspects of
unconscious conflicts. This procedure is often difficult because the patient may resist the efforts of the
therapist to uncover repressed and sensitive conflicts and may deny the interpretations. The goal of this
stage of therapy is to help the patient gain insight into the nature of the conflicts.
The relationship between the therapist, called the psychoanalyst, and the patient is important. In the
context of this relationship as it evolves, the therapist may discover the nature of the patient’s
intrapsychic conflict. This is because, in a phenomenon called transference, patients come to relate to
the therapist much as they did to important figures in their childhood, particularly their parents.
Patients who resent the therapist but can verbalize no good reason for it may be reenacting childhood
resentment toward a parent. More often, the patient will fall deeply in love with the therapist, which
reflects strong positive feelings that existed earlier for a parent. In the phenomenon of
countertransference, therapists project some of their own personal issues and feelings, usually positive,
onto the patient. Therapists are trained to deal with their own feelings as well as those of their patients,
whatever the mode of therapy, and it is strictly against all ethical canons of the mental health
professions to accept overtures from patients that might lead to relationships outside therapy.
Classical psychoanalysis requires therapy four to five times a week for 2 to 5 years to analyze
unconscious conflicts, resolve them, and restructure the personality to put the ego back in charge.
Reduction of symptoms (psychological disorders) is relatively inconsequential because they are only
expressions of underlying intrapsychic conflicts that arise from psychosexual developmental stages.
Thus, eliminating a phobia or depressive episode would be of little use unless the underlying conflict was
dealt with adequately, because another set of symptoms would almost certainly emerge (symptom
substitution). Because of the extraordinary expense of classical psychoanalysis, and the lack of evidence
that it is effective in alleviating psychological disorders, this approach is seldom used today.
Psychoanalysis is still practiced, particularly in some large cities, but many psychotherapists employ a
loosely related set of approaches referred to as psychodynamic psychotherapy. Although conflicts and
unconscious processes are still emphasized, and efforts are made to identify trauma and active defense
mechanisms, therapists use an eclectic mixture of tactics, with a social and interpersonal focus. Seven
tactics that characterize psychodynamic psychotherapy include
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a focus on affect and the expression of patients’ emotions;
an exploration of patients’ attempts to avoid topics or engage in activities that hinder the
progress of therapy;
the identification of patterns in patients’ actions, thoughts, feelings, experiences, and
relationships;
an emphasis on past experiences;
a focus on patients’ interpersonal experiences;
an emphasis on the therapeutic relationship;
an exploration of patients’ wishes, dreams, or fantasies
Two additional features characterize psychodynamic psychotherapy. First, it is significantly briefer than
classical psychoanalysis. Second, psychodynamic therapists deemphasize the goal of personality
reconstruction, focusing instead on relieving the suffering associated with psychological disorders.
Pure psychoanalysis is of historical interest more than current interest, and classical psychoanalysis as a
treatment has been diminishing in popularity for years. In 1980, the term neurosis, which specifically
implied a psychoanalytic view of the causes of psychological disorders, was dropped from the DSM, the
official diagnostic system of the APA.
A major criticism of psychoanalysis is that it is basically unscientific, relying on reports by the patient of
events that happened years ago. These events have been filtered through the experience of the
observer and then interpreted by the psychoanalyst in ways that certainly could be questioned and
might differ from one analyst to the next. Finally, there has been no careful measurement of any of
these psychological phenomena and no obvious way to prove or disprove the basic hypotheses of
psychoanalysis. This is important because measurement and the ability to prove or disprove a theory are
the foundations of the scientific approach.
Nevertheless, psychoanalytic concepts and observations have been valuable, not only to the study of
psychopathology and psychodynamic psychotherapy but also to the history of ideas in Western
civilization. Careful scientific studies of psychopathology have supported the observation of unconscious
mental processes, the notion that basic emotional responses are often triggered by hidden or symbolic
cues, and the understanding that memories of events in our lives can be repressed and otherwise
avoided in a variety of ingenious ways. The relationship of the therapist and the patient, called the
therapeutic alliance, is an important area of study across most therapeutic strategies. These concepts,
along with the importance of various coping styles or defense mechanisms, will appear repeatedly
throughout this book.
Many of these psychodynamic ideas had been in development for more than a century, culminating in
Freud’s influential writings (e.g., Lehrer, 1995), and they stood in stark contrast to witch trials and ideas
of incurable brain pathology. In early years, the source of good and evil and of urges and prohibitions
was conceived as external and spiritual, usually in the guise of demons confronting the forces of good.
From the psychoanalytic point of view, we ourselves became the battleground for these forces, and we
are inexorably caught up in the battle, sometimes for better and sometimes for worse.
Humanistic Theory
We have already seen that Jung and Adler broke sharply with Freud. Their fundamental disagreement
concerned the very nature of humanity. Freud portrayed life as a battleground where we are continually
in danger of being overwhelmed by our darkest forces. Jung and Adler, by contrast, emphasized the
positive, optimistic side of human nature. Jung talked about setting goals, looking toward the future,
and realizing one’s fullest potential. Adler believed that human nature reaches its fullest potential when
we contribute to the welfare of other individuals and to society as a whole. He believed that we all strive
to reach superior levels of intellectual and moral development. Nevertheless, both Jung and Adler
retained many of the principles of psychodynamic thought. Their general philosophies were adopted in
the middle of the century by personality theorists and became known as humanistic psychology.
Self-actualizing was the watchword for this movement. The underlying assumption is that all of us could
reach our highest potential, in all areas of functioning, if only we had the freedom to grow. Inevitably, a
variety of conditions may block our actualization. Because every person is basically good and whole,
most blocks originate outside the individual. Difficult living conditions or stressful life or interpersonal
experiences may move you away from your true self.
Abraham Maslow (1908–1970) was most systematic in describing the structure of personality. He
postulated a hierarchy of needs, beginning with our most basic physical needs for food and sex and
ranging upward to our needs for self-actualization, love, and self-esteem. Social needs such as friendship
fall somewhere between. Maslow hypothesized that we cannot progress up the hierarchy until we have
satisfied the needs at lower levels.
Carl Rogers (1902–1987) is, from the point of view of therapy, the most influential humanist. Rogers
(1961) originated client-centered therapy, later known as person-centered therapy. In this approach, the
therapist takes a passive role, making as few interpretations as possible. The point is to give the
individual a chance to develop during the course of therapy, unfettered by threats to the self. Humanist
theorists have great faith in the ability of human relations to foster this growth. Unconditional positive
regard, the complete and almost unqualified acceptance of most of the client’s feelings and actions, is
critical to the humanistic approach. Empathy is the sympathetic understanding of the individual’s
particular view of the world. The hoped-for result of person-centered therapy is that clients will be more
straightforward and honest with themselves and will access their innate tendencies toward growth.
Like psychoanalysis, the humanistic approach has had a substantial effect on theories of interpersonal
relationships. For example, the human potential movements so popular in the 1960s and 1970s were a
direct result of humanistic theorizing. This approach also emphasized the importance of the therapeutic
relationship in a way quite different from Freud’s approach. Rather than seeing the relationship as a
means to an end (transference), humanistic therapists believed that relationships, including the
therapeutic relationship, were the single most positive influence in facilitating human growth. In fact,
Rogers made substantial contributions to the scientific study of therapist–client relationships.
Nevertheless, the humanistic model contributed relatively little new information to the field of
psychopathology. One reason for this is that its proponents, with some exceptions, had little interest in
doing research that would discover or create new knowledge. Rather, they stressed the unique,
nonquantifiable experiences of the individual, emphasizing that people are more different than alike. As
Maslow noted, the humanistic model found its greatest application among individuals without
psychological disorders. The application of person-centered therapy to more severe psychological
disorders has decreased substantially over the decades, although certain variations have arisen
periodically in some areas of psychopathology.
The Behavioral Model
As psychoanalysis swept the world at the beginning of the 20th century, events in Russia and the United
States would eventually provide an alternative psychological model that was every bit as powerful. The
behavioral model, which is also known as the cognitive-behavioral model or social learning model,
brought the systematic development of a more scientific approach to psychological aspects of
psychopathology.
Pavlov and Classical Conditioning
In his classic study examining why dogs salivate before the presentation of food, physiologist Ivan
Petrovich Pavlov (1849–1936) of St. Petersburg, Russia, initiated the study of classical conditioning, a
type of learning in which a neutral stimulus is paired with a response until it elicits that response.
The word conditioning (or conditioned response) resulted from an accident in translation from the
original Russian. Pavlov was really talking about a response that occurred only on the condition of the
presence of a particular event or situation (stimulus)—in this case, the footsteps of the laboratory
assistant at feeding time. Thus, “conditional response” would have been more accurate. Conditioning is
one way in which we acquire new information, particularly information that is somewhat emotional in
nature. This process is not as simple as it first seems, and we continue to uncover many more facts
about its complexity (Bouton, 2005; Craske, Hermans, & Vansteenwegen, 2006; Lissek et al., 2014;
Prenoveau, Craske, Liao, & Ornitz, 2013; Rescorla, 1988). But it can be quite automatic. Let’s look at a
powerful contemporary example.
Psychologists working in oncology units have studied a phenomenon well known to many cancer
patients, their nurses and physicians, and their families. Chemotherapy, a common treatment for some
forms of cancer, has side effects including severe nausea and vomiting. But these patients often
experience severe nausea and, occasionally, vomiting when they merely see the medical personnel who
administered the chemotherapy or any equipment associated with the treatment, even on days when
their treatment is not delivered (Morrow & Dobkin, 1988; Kamen, et al., 2014; Roscoe, Morrow, Aapro,
Molassiotis, & Olver, 2011). For some patients, this reaction becomes associated with a variety of stimuli
that evoke people or things present during chemotherapy—anybody in a nurse’s uniform or even the
sight of the hospital. The strength of the response to similar objects or people is usually a function of
how similar these objects or people are. This phenomenon is called stimulus generalization because the
response generalizes to similar stimuli. In any case, this particular reaction is distressing and
uncomfortable, particularly if it is associated with a variety of objects or situations. Psychologists have
had to develop specific treatments to overcome this response (Mustian et al., 2011).
Ivan Pavlov (1849–1936) identified the process of classical conditioning, which is important to many
emotional disorders.
Whether the stimulus is food, as in Pavlov’s laboratory, or chemotherapy, the classical conditioning
process begins with a stimulus that would elicit a response in almost anyone and requires no learning;
no conditions must be present for the response to occur. For these reasons, the food or chemotherapy
is called the unconditioned stimulus (UCS). The natural or unlearned response to this stimulus—in these
cases, salivation or nausea—is called the unconditioned response (UCR). Now the learning comes in. As
we have already seen, any person or object associated with the UCS (food or chemotherapy) acquires
the power to elicit the same response, but now the response, because it was elicited by the conditional
or conditioned stimulus (CS), is termed a conditioned response (CR). Thus, the nurse associated with the
chemotherapy becomes a CS. The nauseous sensation (upon seeing the nurse), which is almost the same
as that experienced during chemotherapy, becomes the CR.
With unconditioned stimuli as powerful as chemotherapy, a CR can be learned in one trial. Most
learning of this type, however, requires repeated pairing of the UCS (for example, chemotherapy) and
the CS (for instance, nurses’ uniforms or hospital equipment). When Pavlov began to investigate this
phenomenon, he substituted a metronome for the footsteps of his laboratory assistants so that he could
quantify the stimulus more accurately and, therefore, study the approach more precisely. What he also
learned is that presentation of the CS (for example, the metronome) without the food for a long enough
period would eventually eliminate the CR to the food. In other words, the dog learned that the
metronome no longer meant that a meal might be on the way. This process was called extinction.
Because Pavlov was a physiologist, it was natural for him to study these processes in a laboratory and to
be quite scientific about it. This required precision in measuring and observing relationships and in ruling
out alternative explanations. Although this scientific approach is common in biology, it was uncommon
in psychology at that time. For example, it was impossible for psychoanalysts to measure unconscious
conflicts precisely, or even observe them. Even early experimental psychologists such as Edward
Titchener (1867–1927) emphasized the study of introspection. Subjects simply reported on their inner
thoughts and feelings after experiencing certain stimuli, but the results of this “armchair” psychology
were inconsistent and discouraging to many experimental psychologists.
Watson and the Rise of Behaviorism
An early American psychologist, John B. Watson (1878–1958), is considered the founder of behaviorism.
Strongly influenced by the work of Pavlov, Watson decided that to base psychology on introspection was
to head in the wrong direction; that psychology could be made as scientific as physiology, and that
psychology needs introspection or other nonquantifiable methods no more than chemistry and physics
do (Watson, 1913). This point of view is reflected in a famous quotation from a seminal article published
by Watson in 1913: “Psychology, as the behaviorist views it, is a purely objective experimental branch of
natural science. Its theoretical goal is the prediction and control of behavior. Introspection forms no
essential part of its methods”.
Mary Cover Jones (1896–1987) was one of the first psychologists to use behavioral techniques to free a
patient from phobia.
Most of Watson’s time was spent developing behavioral psychology as a radical empirical science, but
he did dabble briefly in the study of psychopathology. In 1920, he and a student, Rosalie Rayner,
presented an 11-month-old boy named Albert with a harmless fluffy white rat to play with. Albert was
not afraid of the small animal and enjoyed playing with it. Every time Albert reached for the rat,
however, the experimenters made a loud noise behind him. After only five trials, Albert showed the first
signs of fear if the white rat came near. The experimenters then determined that Albert displayed mild
fear of any white furry object, even a Santa Claus mask with a white fuzzy beard. You may not think that
this is surprising, but keep in mind that this was one of the first examples ever recorded in a laboratory
of producing fear of an object not previously feared. Of course, this experiment would be considered
unethical by today’s standards, and it turns out Albert may have also had some neurological impairment
that could have contributed to developing fear (Fridlund, Beck, Goldie, & Irons, 2012), but the study
remains a classic one.
Another student of Watson’s, Mary Cover Jones (1896–1987), thought that if fear could be learned or
classically conditioned in this way, perhaps it could also be unlearned or extinguished. She worked with
a boy named Peter, who at 2 years, 10 months old was already quite afraid of furry objects. Jones
decided to bring a white rabbit into the room where Peter was playing for a short time each day. She
also arranged for other children, whom she knew did not fear rabbits, to be in the same room. She
noted that Peter’s fear gradually diminished. Each time it diminished, she brought the rabbit closer.
Eventually Peter was touching and even playing with the rabbit (Jones, 1924a, 1924b), and years later
the fear had not returned.
The Beginnings of Behavior Therapy
The implications of Jones’s research were largely ignored for two decades, given the fervor associated
with more psychoanalytic conceptions of the development of fear. But in the late 1940s and early 1950s,
Joseph Wolpe (1915–1997), a pioneering psychiatrist from South Africa, became dissatisfied with
prevailing psychoanalytic interpretations of psychopathology and began looking for something else. He
turned to the work of Pavlov and became familiar with the wider field of behavioral psychology. He
developed a variety of behavioral procedures for treating his patients, many of whom suffered from
phobias. His best-known technique was termed systematic desensitization. In principle, it was similar to
the treatment of little Peter: Individuals were gradually introduced to the objects or situations they
feared so that their fear could extinguish; that is, they could test reality and see that nothing bad
happened in the presence of the phobic object or scene. Wolpe added another element by having his
patients do something that was incompatible with fear while they were in the presence of the dreaded
object or situation. Because he could not always reproduce the phobic object in his office, Wolpe had his
patients carefully and systematically imagine the phobic scene, and the response he chose was
relaxation because it was convenient. For example, Wolpe treated a young man with a phobia of dogs by
training him first to relax deeply and then imagine he was looking at a dog across the park. Gradually, he
could imagine the dog across the park and remain relaxed, experiencing little or no fear. Wolpe then had
him imagine that he was closer to the dog. Eventually, the young man imagined that he was touching
the dog while maintaining a relaxed, almost trancelike state.
Wolpe reported great success with systematic desensitization, one of the first wide-scale applications of
the new science of behaviorism to psychopathology. Wolpe, working with fellow pioneers Hans Eysenck
and Stanley Rachman in London, called this approach behavior therapy. Although Wolpe’s procedures
are seldom used today, they paved the way for modern-day fear and anxiety reduction procedures in
which severe phobias can be eliminated in as little as 1 day (see Chapter 5).
B. F. Skinner and Operant Conditioning
Sigmund Freud’s influence extended far beyond psychopathology into many aspects of our cultural and
intellectual history. Only one other behavioral scientist has made a similar impact: Burrhus Frederic (B.
F.) Skinner (1904–1990). In 1938 he published The Behavior of Organisms, in which he laid out, in a
comprehensive manner, the principles of operant conditioning, a type of learning in which behavior
changes as a function of what follows the behavior. Skinner observed early on that a large part of our
behavior is not automatically elicited by a UCS and that we must account for this. In the ensuing years,
Skinner did not confine his ideas to the laboratories of experimental psychology. He ranged far and wide
in his writings, describing, for example, the potential applications of a science of behavior to our culture.
Some best-known examples of his ideas are in the novel Walden Two (Skinner, 1948), in which he
depicts a fictional society run on the principles of operant conditioning. In another well-known work,
Beyond Freedom and Dignity (1971), Skinner lays out a broader statement of problems facing our
culture and suggests solutions based on his own view of a science of behavior.
Skinner was strongly influenced by Watson’s conviction that a science of human behavior must be based
on observable events and relationships among those events. The work of psychologist Edward L.
Thorndike (1874–1949) also influenced Skinner. Thorndike is best known for the law of effect, which
states that behavior is either strengthened (likely to be repeated more frequently) or weakened (likely
to occur less frequently) depending on the consequences of that behavior. Skinner took the simple
notions that Thorndike had tested in the animal laboratories, using food as a reinforcer, and developed
them in a variety of complex ways to apply to much of our behavior. For example, if a 5-year-old boy
starts shouting at the top of his lungs in a restaurant, much to the annoyance of the people around him,
it is unlikely that his behavior was automatically elicited by a UCS. Also, he will be less likely to do it in
the future if his parents scold him, take him out to the car to sit for a bit, or consistently reinforce more
appropriate behavior. Then again, if the parents think his behavior is cute and laugh, chances are he will
do it again.
B. F. Skinner (1904–1990) studied operant conditioning, a form of learning that is central to
psychopathology.
B. F. Skinner (1904–1990) studied operant conditioning, a form of learning that is central to
psychopathology.
Bettmann/Getty Images
Skinner coined the term operant conditioning because behavior operates on the environment and
changes it in some way. For example, the boy’s behavior affects his parents’ behavior and probably the
behavior of other customers. Therefore, he changes his environment. Most things that we do socially
provide the context for other people to respond to us in one way or another, thereby providing
consequences for our behavior. The same is true of our physical environment, although the
consequences may be long term (polluting the air eventually will poison us). Skinner preferred the term
reinforcement to “reward” because it connotes the effect on the behavior. Skinner once said that he
found himself a bit embarrassed to be talking continually about reinforcement, much as Marxists used
to see class struggle everywhere. But he pointed out that all of our behavior is governed to some degree
by reinforcement, which can be arranged in an endless variety of ways, in schedules of reinforcement.
Skinner wrote a whole book on different schedules of reinforcement (Ferster & Skinner, 1957). He also
believed that using punishment as a consequence is relatively ineffective in the long run and that the
primary way to develop new behavior is to positively reinforce desired behavior. Much like Watson,
Skinner did not see the need to go beyond the observable and quantifiable to establish a satisfactory
science of behavior. He did not deny the influence of biology or the existence of subjective states of
emotion or cognition; he simply explained these phenomena as relatively inconsequential side effects of
a particular history of reinforcement.
The subjects of Skinner’s research were usually animals, mostly pigeons and rats. Using his new
principles, Skinner and his disciples taught the animals a variety of tricks, including dancing, playing PingPong, and playing a toy piano. To do this he used a procedure called shaping, a process of reinforcing
successive approximations to a final behavior or set of behaviors. For example, if you want a pigeon to
play Ping-Pong, first you provide it with a pellet of food every time it moves its head slightly toward a
Ping-Pong ball tossed in its direction. Gradually you require the pigeon to move its head ever closer to
the Ping-Pong ball until it touches it. Finally, receiving the food pellet is contingent on the pigeon hitting
the ball back with its head.
Pavlov, Watson, and Skinner contributed significantly to behavior therapy (see, for example, Wolpe,
1958), in which scientific principles of psychology are applied to clinical problems. Their ideas have
substantially contributed to current psychological treatments and so are referred to repeatedly in this
book.
Comments
The behavioral model has contributed greatly to the understanding and treatment of psychopathology,
as is apparent in the chapters that follow. Nevertheless, this model is incomplete and inadequate to
account for what we now know about psychopathology. In the past, there was little or no room for
biology in behaviorism, because disorders were considered, for the most part, environmentally
determined reactions. The model also fails to account for development of psychopathology across the
life span. Recent advances in our knowledge of how information is processed, both consciously and
subconsciously, have added a layer of complexity. Integrating all these dimensions requires a new model
of psychopathology.
The Present: The Scientific Method and an Integrative Approach
As William Shakespeare wrote, “What’s past is prologue.” We have just reviewed three traditions or
ways of thinking about causes of psychopathology: the supernatural, the biological, and the
psychological (further subdivided into two major historical components: psychoanalytic and behavioral).
Supernatural explanations of psychopathology are still with us. Superstitions prevail, including beliefs in
the effects of the moon and the stars on our behavior. This tradition has little influence on scientists and
other professionals, however. Biological, psychoanalytic, and behavioral models, by contrast, continue
to further our knowledge of psychopathology, as you will see in the next chapter.
Each tradition has failed in important ways. First, scientific methods were not often applied to the
theories and treatments within a tradition, mostly because methods that would have produced the
evidence necessary to confirm or disprove the theories and treatments had not been developed. Lacking
such evidence, many people accepted various fads and superstitions that ultimately proved to be untrue
or useless. New fads often superseded truly useful theories and treatment procedures. King Charles VI
was subjected to a variety of procedures, some of which have since been proved useful and others that
were mere fads or even harmful. How we use scientific methods to confirm or disconfirm findings in
psychopathology is described in Chapter 4. Second, health professionals tend to look at psychological
disorders narrowly, from their own point of view alone. Grey assumed that psychological disorders were
the result of brain disease and that other factors had no influence. Watson assumed that all behaviors,
including disordered behavior, were the result of psychological and social influences and that the
contribution of biological factors was inconsequential.
In the 1990s, two developments came together as never before to shed light on the nature of
psychopathology:
the increasing sophistication of scientific tools and methodology, and
the realization that no one influence—biological, behavioral, cognitive, emotional, or social—ever
occurs in isolation. Literally, every time we think, feel, or do something, the brain and the rest of the
body are hard at work. Perhaps not as obvious, however, is that our thoughts, feelings, and actions
inevitably influence the function and even the structure of the brain, sometimes permanently. In other
words, our behavior, both normal and abnormal, is the product of a continual interaction of
psychological, biological, and social influences.
The view that psychopathology is multiply determined had its early adherents. Perhaps the most
notable was Adolf Meyer (1866–1950), often considered the dean of American psychiatry. Whereas
most professionals during the first half of the century held narrow views of the cause of
psychopathology, Meyer steadfastly emphasized the equal contributions of biological, psychological,
and sociocultural determinism. Although Meyer’s ideas had some proponents, it was 100 years before
the wisdom of his advice was fully recognized in the field.
By 2000, a veritable explosion of knowledge about psychopathology was occurring. The young fields of
cognitive science and neuroscience began to grow exponentially as we learned more about the brain
and about how we process, remember, and use information. At the same time, startling new findings
from behavioral science revealed the importance of early experience in determining later development.
It was clear that a new model was needed that would consider biological, psychological, and social
influences on behavior. This approach to psychopathology would combine findings from all areas with
our rapidly growing understanding of how we experience life during different developmental periods,
from infancy to old age. In 2010, the National Institute of Mental Health (NIMH) instituted a strategic
plan to support further research and development on the interrelationship of these factors with the aim
of translating research findings to front-line treatment settings (Cuthbert, 2014; Insel, 2009; Sanislow,
Quinn, & Sypher, 2015). In the remainder of this book, we explore the reciprocal influences among
neuroscience, cognitive science, behavior science, and developmental science and demonstrate that the
only currently valid model of psychopathology is multidimensional and integrative.
Review the major psychological models of abnormal behavior. We will be taking a trip down
psychology's memory lane as we travel across the twentieth century through some of the most
influential theories of the 1900's. Let's begin at the turn of the 20th century when the field of
psychology was forever changed by theories of the one and only Sigmund Freud. Collectively, Freud's
theories are referred to as the psychoanalytic perspective. In Freud's view, one's psychological makeup
is determined by our earliest childhood experiences; especially the first 6 years of life. Of these earliest
experiences none are more influential than those with our parents. According to Freud, the dynamics of
these relationships will play a significant influence in our future relationships, and other areas of
functioning. Finally, the psychoanalytic perspective places great emphasis on the role of the
psychological forces of which we are not aware and cannot access. Freud believed that these
unconscious forces were mostly sexual, but also aggressive in nature. Moving on to behaviorism, this is a
model that argues that human nature can be explained simply by looking at overt observable behaviors.
In essence, the idea that you are what you do. In the early 1900s noted Russian physiologist named Ivan
Pavlov made a groundbreaking while working with dogs. He discovered that he could train dogs to
salivate in response to any stimulus that the dog could perceive. For instance, if he repeatedly paired
food, which naturally elicits the salivary response in dogs, with the sound of a bell, eventually the bell
alone would begin to elicit that very response. Pavlov had discovered an unconscious learning process
now referred to as classical conditioning. If reliably paired with an unconditioned stimulus like food, a
neutral stimulus like a bell will begin to evoke an unlearned automatic biological response like the
salivary response. Classical conditioning was popularized in the 1920s by psychologist John B. Watson
with his famous Little Albert study. Using classical conditioning Watson was able to train an infant to
fear furry things like a mouse. Watson went on to have a very successful career in advertising. Another
important area of behaviorism centers around a different type learning called operant conditioning.
Most would argue that the most prominent figure involved in the study of operant conditioning is BF
Skinner, a man who devoted his life's work to researching and writing about it. Operant conditioning is
learning in which voluntary responses are shaped by the consequences. The 2 broad types of
consequences are reinforcements, which strengthen or increase a response; and punishments, which
weaken or decrease a response. In the mid-1900s, an approach referred to as humanistic psychology
was popularized by these two key individuals, Abraham Maslow and Carl Rogers. This is an approach
that emphasizes the positive nature of human beings, framing our species as innately good and growth
seeking. According to Maslow, all humans naturally strive to move up the ladder or hierarchy of needs
toward an enlightening state Maslow referred to as self actualization. Carl Rogers developed the unique
approach to psychotherapy now referred to as person centered therapy. This is an approach that
emphasizes the importance of being respectful and nonjudgmental towards others, what Rogers termed
unconditional positive regard. It also emphasizes the importance of being a empathic towards others,
putting ourselves in others shoes. Finally we have the cognitive perspective, a model that emphasizes
the influence of our thoughts, beliefs and attitudes on other areas of functioning. In abnormal
psychology this model was made popular by Aaron Beck and Albert Ellis, both who developed unique
approaches to cognitive behavioral therapy independent of each other in the 1950s and 60s. Albert
Ellis's approach called rational emotive behavioral therapy, or REBT, focuses on the influence of our
deep-seated beliefs. Ellis proposed that individuals whose belief systems are consumed by irrational
beliefs are likely to be psychologically disturbed; and replacing these beliefs with more rational ones will
relieve them of this disturbance. Aaron Beck's original work was focused on the treatment of
depression. Beck found that individuals who are depressed are typically plagued by severe errors or
distortions in thought. Aaron Beck's approach to treatment, called cognitive therapy, is now considered
one of the best treatments for clinical depression.
Projection: involves attributing your own unacceptable thoughts and feelings to another. In this case,
Jack is projecting his desire to break up onto his partner.
Superego - Go over to his house because you have been close and he deserves to hear this
news in person.
The earliest explanations for psychological disorders were based on religious and supernatural
beliefs. For example, many believed that abnormal behavior was due to possession by demons
or evil spirits. Hippocrates was one of the first to consider the role of biology in causing
psychological disorders.
Alison is expressing a supernatural view because evil spirits refers to something outside or
beyond the natural world. Common treatments adopted by those who believe in supernatural
explanations for abnormal behavior include exorcism and prayer.
All of these individuals are known for their work to reform asylums by providing more humane
and therapeutic treatment of patients. Before the reform efforts of individuals such as these,
the earliest asylums functioned more as prisons than hospitals or treatment centers.
Albert is expressing a humoral view because bloodletting and induced vomiting were
treatments used to attempt to bring the four humors back in balance. This view originated with
Hippocrates and the ancient Greeks and is perhaps the first example of associating
psychological disorders with a chemical imbalance in the body.
In the client-centered approach, the client largely dictates the direction and pace of treatment.
The therapist establishes a supportive environment, allows clients to determine what topics are
broached and into how much depth or detail the therapy goes, and encourages them to express
themselves without worrying about being judged. The humanistic framework of this approach
states that the primary benefit for the client is the ability to conduct self-examination and
develop a self-image that is rooted in reality.
If someone is suffering from a mild disorder with acute onset that we know is time limited, we
might advise the individual not to bother with expensive treatment because the problem will be
over soon enough, like a common cold.
If the disorder is likely to last a long time (become chronic), however, the individual might want
to seek treatment and take other appropriate steps. The anticipated course of a disorder is
called the prognosis. So, we might say, “the prognosis is good,” meaning the individual will
probably recover, or “the prognosis is guarded,” meaning the probable outcome doesn’t look
good.
The patient’s age may be an important part of the clinical description. A specific psychological
disorder occurring in childhood may present differently from the same disorder in adulthood or
old age.
Children experiencing severe anxiety and panic often assume that they are physically ill
because they have difficulty understanding that there is nothing physically wrong. Because
their thoughts and feelings are different from those experienced by adults with anxiety and
panic, children are often misdiagnosed and treated for a medical disorder.
We call the study of changes in behavior over time developmental psychology, and we refer to
the study of changes in abnormal behavior as developmental psychopathology. When you think
of developmental psychology, you probably picture researchers studying the behavior of
children. We change throughout our lives, however, and so researchers also study
development in adolescents, adults, and older adults. Study of abnormal behavior across the
entire age span is referred to as life-span developmental psychopathology. The field is relatively
new but expanding rapidly.
Etiology, or the study of origins, has to do with why a disorder begins (what causes it) and
includes biological, psychological, and social dimensions. Because the etiology of psychological
disorders is so important to this field, we devote an entire chapter (Chapter 2) to it.
Treatment, also, is often important to the study of psychological disorders. If a new drug or
psychosocial treatment is successful in treating a disorder, it may give us some hints about the
nature of the disorder and its causes. For example, if a drug with a specific known effect within
the nervous system alleviates a certain psychological disorder, we know that something in that
part of the nervous system might either be causing the disorder or helping maintain it.
Similarly, if a psychological treatment designed to help clients regain a sense of control over
their lives is effective with a certain disorder, a diminished sense of control may be an
important psychological component of the disorder itself.
As you will see in the next chapter, psychopathology is rarely simple. This is because the effect
does not necessarily imply the cause.
To use a common example, you might take an aspirin to relieve a tension headache you
developed during a grueling day of taking exams. If you then feel better, that does not mean
that the headache was caused by a lack of aspirin. Nevertheless, many people seek treatment
for psychological disorders, and treatment can provide interesting hints about the nature of
the disorder.
In the past, textbooks emphasized treatment approaches in a general sense, with little
attention to the disorder being treated. For example, a mental health professional might be
thoroughly trained in a single theoretical approach, such as psychoanalysis or behavior therapy
(both described later in the chapter), and then use that approach on every disorder. More
recently, as our science has advanced, we have developed specific effective treatments that do
not always adhere neatly to one theoretical approach or another but that have grown out of a
deeper understanding of the disorder in question.
Rather, the latest and most effective drug and psychosocial treatments (nonmedical treatments
that focus on psychological, social, and cultural factors) are described in the context of specific
disorders in keeping with our integrative multidimensional perspective.
We review research methods—our systematic efforts to discover the truths underlying
description, cause, and treatment that allow us to function as scientist-practitioners.
We examine specific disorders; our discussion is organized in each case in the now familiar
triad of description, cause, and treatment. Finally, in Chapter 16 we examine legal,
professional, and ethical issues relevant to psychological disorders and their treatment today.
With that overview in mind, let us turn to the past.
For thousands of years, humans have tried to explain and control problematic behavior. But our
efforts always derive from the theories or models of behavior popular at the time. The purpose
of these models is to explain why someone is “acting like that.” Three major models that have
guided us date back to the beginnings of civilization.
Humans have always supposed that agents outside our bodies and environment influence our
behavior, thinking, and emotions. These agents—which might be divinities, demons, spirits, or
other phenomena such as magnetic fields or the moon or the stars—are the driving forces
behind the supernatural model.
In addition, since the era of ancient Greece, the mind has often been called the soul or the
psyche and considered separate from the body. Although many have thought that the mind
can influence the body and, in turn, the body can influence the mind, most philosophers looked
for causes of abnormal behavior in one or the other. This split gave rise to two traditions of
thought about abnormal behavior, summarized as the biological model and the psychological
model. These three models—the supernatural, the biological, and the psychological—are very
old but continue to be used today.
For much of our recorded history, deviant behavior has been considered a reflection of the
battle between good and evil. When confronted with unexplainable, irrational behavior and by
suffering and upheaval, people have perceived evil. In fact, in the Great Persian Empire from
900 to 600 b.c., all physical and mental disorders were considered the work of the devil
(Millon, 2004). Barbara Tuchman, a noted historian, chronicled the second half of the 14th
century, a particularly difficult time for humanity, in A Distant Mirror (1978). She ably captures
the conflicting tides of opinion on the origins and treatment of insanity during that bleak and
tumultuous period.
One strong current of opinion put the causes and treatment of psychological disorders
squarely in the realm of the supernatural. During the last quarter of the 14th century, religious
and lay authorities supported these popular superstitions, and society as a whole began to
believe more strongly in the existence and power of demons and witches. The Catholic Church
had split, and a second center, complete with a pope, emerged in the south of France to
compete with Rome. In reaction to this schism, the Roman Church fought back against the evil
in the world that it believed must have been behind this heresy.
People increasingly turned to magic and sorcery to solve their problems. During these
turbulent times, the bizarre behavior of people afflicted with psychological disorders was seen
as the work of the devil and witches. It followed that individuals possessed by evil spirits were
probably responsible for any misfortune experienced by people in the local community, which
inspired drastic action against the possessed. Treatments included exorcism, in which various
religious rituals were performed in an effort to rid the victim of evil spirits. Other approaches
included shaving the pattern of a cross in the hair of the victim’s head and securing sufferers to
a wall near the front of a church so that they might benefit from hearing Mass.
The conviction that sorcery and witches are causes of madness and other evils continued into
the 15th century, and evil continued to be blamed for unexplainable behavior, even after the
founding of the United States, as evidenced by the Salem, Massachusetts, witch trials in the
late 17th century, which resulted in the hanging deaths of 20 women.
An equally strong opinion, even during this period, reflected the enlightened view that insanity
was a natural phenomenon, caused by mental or emotional stress, and that it was curable
(Alexander & Selesnick, 1966; Maher & Maher, 1985a). Mental depression and anxiety were
recognized as illnesses (Kemp, 1990; Schoeneman, 1977), although symptoms such as despair
and lethargy were often identified by the church with the sin of acedia, or sloth (Tuchman,
1978). Common treatments were rest, sleep, and a healthy and happy environment. Other
treatments included baths, ointments, and various potions. Indeed, during the 14th and 15th
centuries, people with insanity, along with those with physical deformities or disabilities, were
often moved from house to house in medieval villages as neighbors took turns caring for them.
We now know that this medieval practice of keeping people who have psychological
disturbances in their own community is beneficial. We return to this subject when we discuss
biological and psychological models later in this chapter.
To date, however, the most advanced neuroscience research in psychopathology focuses on
neurons. Major neurotransmitters relevant to psychopathology include norepinephrine (also
known as noradrenaline), serotonin, dopamine, gamma-aminobutyric acid (GABA), and
glutamate. You will see these terms many times in this book. Some neurotransmitters are
excitatory, because they increase the likelihood that the connecting neuron will fire, whereas
other neurotransmitters are inhibitory because they decrease the likelihood that the
connecting neuron will fire. Some neurons can receive input from both excitatory and inhibitory
neurotransmitters.
Excesses or insufficiencies in some neurotransmitters are associated with different groups of
psychological disorders. Reduced levels of GABA were initially thought to be associated with
excessive anxiety (Costa, 1985). Early research (Snyder, 1976, 1981) linked increases in
dopamine activity to schizophrenia. Other early research found correlations between
depression and high levels of norepinephrine (Schildkraut, 1965) and, possibly, low levels of
serotonin (Siever, Davis, & Gorman, 1991). However, more recent research, described later in
this chapter, indicates that these early interpretations were too simplistic. In view of their
importance, we return to the subject of neurotransmitters shortly.
Research on neurotransmitter function focuses primarily on what happens when activity levels
change. We can study this in several ways. We can introduce substances called agonists that
effectively increase the activity of a neurotransmitter by mimicking its effects; substances
called antagonists that decrease, or block, a neurotransmitter; or substances called inverse
agonists that produce effects opposite to those produced by the neurotransmitter. By
systematically manipulating the production of a neurotransmitter in different parts of the brain,
scientists are able to learn more about its effects. Most drugs could be classified as either
agonistic or antagonistic, although they may achieve these results in a variety of ways.
However, given advances in pharmacology, genetics, and chemical neuroanatomy, the term
"neurotransmitter" can be applied to chemicals that:



Carry messages between neurons via influence on the postsynaptic membrane.
Have little or no effect on membrane voltage, but have a common carrying function such as
changing the structure of the synapse.
Communicate by sending reverse-direction messages that affect the release or reuptake of
transmitters.
example, reduced levels of GABA were initially thought to be associated with excessive anxiety
(Costa, 1985). Early research (Snyder, 1976, 1981) linked increases in dopamine activity to
schizophrenia. Other early research found correlations between depression and high levels of
norepinephrine (Schildkraut, 1965) and, possibly, low levels of serotonin (Siever, Davis, &
Gorman, 1991). However, more recent research, described later in this chapter, indicates that
these early interpretations were too simplistic. In view of their importance, we return to the
subject of neurotransmitters shortly.
Enormous progress has been made in understanding behavioral and cognitive influences in
psychopathology. Some new information has come from the rapidly growing field of cognitive
science, which is concerned with how we acquire and process information and how we store
and ultimately retrieve it (one of the processes involved in memory). Scientists have also
discovered that we are not necessarily aware of a great deal of what goes on inside our heads.
Because, technically, these cognitive processes are unconscious, some findings recall the
unconscious mental processes that are so much a part of Sigmund Freud’s theory of
psychoanalysis (although they do not look much like the ones he envisioned). A brief account
of current thinking on what is happening during the process of classical conditioning will start
us on our way.
Why isn't psychological dysfunction alone enough to serve as a criterion for a psychological
disorder? Many behaviors and emotions exist along a continuum, and it can be difficult to
distinguish between what is normal and abnormal.
The atypical criterion is based on the notion of social appropriateness. Cultures have norms
that determine what kinds of behavior are acceptable. Appropriateness can be violated either
by going against social norms or by being highly unusual or peculiar. Social norms and
expectations vary widely from culture to culture. These differences have implications on the
diagnosis and prevalence of psychological disorders. For example, hearing voices and sensing
the presence of an invisible spirit may be widely accepted in some cultures, but in the United
States such behaviors are often associated with psychosis. For other disorders, the standards of
what constitutes abnormality differ across cultures. In all cases, the context in which a behavior
occurs must be considered, especially because it often determines whether the behavior is
justifiable. For example, most people would consider it odd to spend an entire week in bed. If
you happen to be a famous rock star and you're staging the action in order to raise publicity
and draw attention to a particular cause, however, spending an entire week in bed seems more
reasonable.
Personal distress sometimes, though not always, includes some form of impairment. Which of
the following is the best description of impairment, as it relates to psychopathology? An
individual is unable to engage in desired behaviors as a result of his or her condition.
Psychological dysfunction indicates a breakdown of cognition (thinking), emotional functioning
(feeling), or behavior (acting). For example, someone with schizophrenia may experience
delusional or disorganized thoughts, may lack emotionality, and may have bizarre mannerisms.
These breakdowns don't necessarily imply that someone with a psychological disorder is
dangerous. They simply indicate the possible presence of a disorder. Deviation from societal
norms can be an indication of a disorder, but it is a different criterion than psychological
dysfunction.
Personal distress occurs when someone is sufficiently bothered or upset about his or her
condition. The person senses or feels that some aspect of his or her life isn't right. This can be,
but isn't always, driven by some form of impairment. The person is prevented from engaging in
some desired behavior or achieving some goal, leading to dissatisfaction or sadness. Personal
distress is not always present in a disorder, however. Some disorders are characterized by a
lack of emotion, while others are defined by feelings of intense elation. For these reasons,
personal distress cannot be the sole criterion used to define psychological disorders. Other
factors must also be considered.
Maladaptive behavior pertains to whether a person's behavior interferes with his or her ability
to function on a daily basis. You needed to identify that this is Dr. Lane's goal when making a
note to investigate the level of impairment of Eric's daily functioning.
In order for Dr. Lane to classify Eric's particular behavior as abnormal, it would need to hinder
his ability to function on a daily basis. Being in danger of losing a job is an example of the
maladaptive behavior criterion necessary for Dr. Lane to classify Eric's behavior as abnormal.
Deviance is the criterion that Dr. Girard's notes address. Deviance pertains to whether a
person's behavior deviates from the social norm. Taking into consideration a person's
environment and culture allows a clinician to better assess whether the person's behavior is
abnormal. You needed to identify that this is Dr. Girard's goal when making a note to
investigate whether Juanita's behavior is socially acceptable.
Personal distress is the criterion that Dr. Frank's notes address. Personal distress pertains to
whether a person's behavior causes personal discomfort or torment. You needed to identify
that this is Dr. Frank's goal when making a note to investigate the level of pain and suffering
Darnell is experiencing.
In psychology, a scientist-practitioner is someone who takes a scientific approach to his or her
clinical and applied work. In particular, a scientist–practitioner serves as a consumer of science,
evaluator of science, and/or creator of science. The following table explains why each of these
mental health professionals does or does not appear to be a scientist–practitioner:
Mental Health Professional
1.) Terese does not appear to be a scientist–practitioner because she does not seem to value
the scientific evaluation of the effectiveness of therapy.
2.) Dmitri does not appear to be a scientist–practitioner because he does not base his practice
on current scientific evidence.
3.) Alison does appear to be a scientist–practitioner because she is evaluating science by
carefully examining the impact of her practice.
This graph displays data on incidence, which is a measure of the number of new cases of a
disorder during a given time period. Of these disorders, social phobia has the highest incidence,
with nearly 4% of US citizens diagnosed with this disorder each year.
Prevalence refers to the total number of people in a population who have a particular disorder.
A high rate of incidence does not necessarily indicate a high rate of prevalence.
Knowing about the onset and course of a disorder gives the therapist an idea of how to proceed
with treatment. There are no broad generalizations that can be made regarding treatment.
Each patient must be evaluated individually, but if a condition is likely to be time-limited, the
therapist may recommend doing nothing. If a condition is likely to be chronic, the therapist can
formulate a treatment plan that allows the patient to manage his or her symptoms.
Course refers to the typical pattern of a disorder, so the psychiatric nurse is talking specifically
about the course of the client's disorder.
Etiology refers to the study of the causes of psychological disorders, prevalence refers to the
number of people in the population who have a disorder, and treatment refers to the method
of helping a person recover from or manage a disorder. All of these issues can be related to the
course of the disorder, but they are not specifically what the psychiatric nurse is talking about
in this case.
This graph displays data on prevalence, which is a measure of the total number of people in a
population who have a particular disorder. Of these states, Colorado has the lowest prevalence
of depression, with just over 6% of its residents meeting criteria for the disorder.
Incidence refers to the number of new cases of a disorder that occur during a given time period,
such as a year. A low rate of prevalence does not necessarily indicate a low rate of incidence.
Many disorders can appear during any stage of life. Diagnosis and treatment of a disorder,
however, will be affected by the age of the patient. A young child may not be able to
adequately describe how he or she is feeling. Presentation, severity, and effects of a disorder
will be different for children, adolescents, adults, and elderly patients. Examining
psychopathology at different stages of life provides therapists with the tools to correctly
identify what is happening and the best way to respond.
Of all of the following, which would not be found in the definition of a psychological disorder?
The Supernatural Tradition
For much of our recorded history, deviant behavior has been considered a reflection of the battle
between good and evil. When confronted with unexplainable, irrational behavior and by
suffering and upheaval, people have perceived evil. In fact, in the Great Persian Empire from 900
to 600, all physical and mental disorders were considered the work of the devil (Millon, 2004).
Barbara Tuchman, a noted historian, chronicled the second half of the 14th century, a
particularly difficult time for humanity, in A Distant Mirror (1978). She ably captures the
conflicting tides of opinion on the origins and treatment of insanity during that bleak and
tumultuous period.
Demons and Witches
One strong current of opinion put the causes and treatment of psychological disorders squarely in
the realm of the supernatural. During the last quarter of the 14th century, religious and lay
authorities supported these popular superstitions, and society as a whole began to believe more
strongly in the existence and power of demons and witches. The Catholic Church had split, and a
second center, complete with a pope, emerged in the south of France to compete with Rome. In
reaction to this schism, the Roman Church fought back against the evil in the world that it
believed must have been behind this heresy.
People increasingly turned to magic and sorcery to solve their problems. During these turbulent
times, the bizarre behavior of people afflicted with psychological disorders was seen as the work
of the devil and witches. It followed that individuals possessed by evil spirits were probably
responsible for any misfortune experienced by people in the local community, which inspired
drastic action against the possessed. Treatments included exorcism, in which various religious
rituals were performed in an effort to rid the victim of evil spirits. Other approaches included
shaving the pattern of a cross in the hair of the victim’s head and securing sufferers to a wall near
the front of a church so that they might benefit from hearing Mass.
The conviction that sorcery and witches are causes of madness and other evils continued into the
15th century, and evil continued to be blamed for unexplainable behavior, even after the
founding of the United States, as evidenced by the Salem, Massachusetts, witch trials in the late
17th century, which resulted in the hanging deaths of 20 women.
Stress and Melancholy
An equally strong opinion, even during this period, reflected the enlightened view that insanity
was a natural phenomenon, caused by mental or emotional stress, and that it was curable
(Alexander & Selesnick, 1966; Maher & Maher, 1985a). Mental depression and anxiety were
recognized as illnesses (Kemp, 1990; Schoeneman, 1977), although symptoms such as despair
and lethargy were often identified by the church with the sin of acedia, or sloth (Tuchman,
1978). Common treatments were rest, sleep, and a healthy and happy environment. Other
treatments included baths, ointments, and various potions. Indeed, during the 14th and 15th
centuries, people with insanity, along with those with physical deformities or disabilities, were
often moved from house to house in medieval villages as neighbors took turns caring for them.
We now know that this medieval practice of keeping people who have psychological
disturbances in their own community is beneficial (see Chapter 13). We return to this subject
when we discuss biological and psychological models later in this chapter.
Treatments for Possession
With a perceived connection between evil deeds and sin on the one hand and psychological
disorders on the other, it is logical to conclude that the sufferer is largely responsible for the
disorder, which might well be a punishment for evil deeds. Does this sound familiar? The
acquired immune deficiency syndrome (AIDS) epidemic was associated with a similar belief
among some people, particularly in the late 1980s and early 1990s. Because the human
immunodeficiency virus (HIV) is, in Western societies, most prevalent among individuals with
homosexual orientation, many people believed it was a divine punishment for what they
considered immoral behavior. This view became less common as the AIDS virus spread to other
segments of the population, yet it persists.
Possession, however, is not always connected with sin but may be seen as involuntary and the
possessed individual as blameless. Furthermore, exorcisms at least have the virtue of being
relatively painless. Interestingly, they sometimes work, as do other forms of faith healing, for
reasons we explore in subsequent chapters. But what if they did not? In the Middle Ages, if
exorcism failed, some authorities thought that steps were necessary to make the body
uninhabitable by evil spirits, and many people were subjected to confinement, beatings, and
other forms of torture (Kemp, 1990).
Somewhere along the way, a creative “therapist” decided that hanging people over a pit full of
poisonous snakes might scare the evil spirits right out of their bodies (to say nothing of terrifying
the people themselves). Strangely, this approach sometimes worked; that is, the most disturbed,
oddly behaving individuals would suddenly come to their senses and experience relief from their
symptoms, if only temporarily. Naturally, this was reinforcing to the therapist, so snake pits were
built in many institutions. Many other treatments based on the hypothesized therapeutic element
of shock were developed, including dunkings in ice-cold water.
Mass Hysteria
Another fascinating phenomenon is characterized by large-scale outbreaks of bizarre behavior.
To this day, these episodes puzzle historians and mental health practitioners. During the Middle
Ages, they lent support to the notion of possession by the devil. In Europe, whole groups of
people were simultaneously compelled to run out in the streets, dance, shout, rave, and jump
around in patterns as if they were at a particularly wild party late at night (still called
a rave today, but with music). This behavior was known by several names, including Saint
Vitus’s Dance and tarantism. It is most interesting that many people behaved in this strange way
at once. In an attempt to explain the inexplicable, several reasons were offered in addition to
possession. One reasonable guess was reaction to insect bites. Another possibility was what we
now call mass hysteria (Veith, 1965). Consider the following example.
In hydrotherapy, patients were shocked back to their senses by applications of ice-cold water.
Modern Mass Hysteria
One Friday afternoon, an alarm sounded over the public address system of a community hospital,
calling all physicians to the emergency room immediately. Arriving from a local school in a fleet
of ambulances were 17 students and 4 teachers who reported dizziness, headache, nausea, and
stomach pains. Some were vomiting; most were hyperventilating.
All the students and teachers had been in four classrooms, two on each side of the hallway. The
incident began when a 14-year-old girl reported a funny smell that seemed to be coming from a
vent. She fell to the floor, crying and complaining that her stomach hurt and her eyes stung.
Soon, many of the students and most of the teachers in the four adjoining classrooms, who could
see and hear what was happening, experienced similar symptoms. Of 86 susceptible people (82
students and 4 teachers in the four classrooms), 21 patients (17 students and 4 teachers)
experienced symptoms severe enough to be evaluated at the hospital. Inspection of the school
building by public health authorities revealed no apparent cause for the reactions, and physical
examinations by teams of physicians revealed no physical abnormalities. All the patients were
sent home and quickly recovered (Rockney & Lemke, 1992).
Mass hysteria may simply demonstrate the phenomenon of emotion contagion, in which the
experience of an emotion seems to spread to those around us (Hatfield, Cacioppo, & Rapson,
1994; Ntika, Sakellariou, Kefalas, & Stamatpoulou, 2014; Wang, 2006). If someone nearby
becomes frightened or sad, chances are that, for the moment, you also will feel fear or sadness.
When this kind of experience escalates into full-blown panic, whole communities are affected
(Barlow, 2002). People are also suggestible when they are in states of high emotion. Therefore, if
one person identifies a “cause” of the problem, others will probably assume that their own
reactions have the same source. In popular language, this shared response is sometimes referred
to as mob psychology. Until recently, it was assumed that victims had to be in contact with each
other for the contagion to occur, as were the girls described above in the adjacent classrooms.
But lately there are documented cases of emotion contagion occurring across social networks,
raising the possibility that episodes of mass hysteria may increase (Bartholomew, Wessely, &
Rubin, 2012; Dimon, 2013)
The Moon and the Stars
Paracelsus, a Swiss physician who lived from 1493 to 1541, rejected notions of possession by the
devil, suggesting instead that the movements of the moon and stars had profound effects on
people’s psychological functioning. Echoing similar thinking in ancient Greece, Paracelsus
speculated that the gravitational effects of the moon on bodily fluids might be a possible cause of
mental disorders (Rotton & Kelly, 1985). This influential theory inspired the word lunatic, which
is derived from the Latin word luna, meaning “moon.” You might hear some of your friends
explain something crazy they did one night by saying, “It must have been the full moon.” The
belief that heavenly bodies affect human behavior still exists, although there is no scientific
evidence to support it (Raison, Klein, & Steckler, 1999; Rotton & Kelly, 1985). Despite much
ridicule, millions of people around the world are convinced that their behavior is influenced by
the stages of the moon or the positions of the stars. This belief is most noticeable today in
followers of astrology, who hold that their behavior and the major events in their lives can be
predicted by their day-to-day relationship to the position of the planets. No serious evidence has
ever confirmed such a connection, however.
Comments
The supernatural tradition in psychopathology is alive and well, although it is relegated, for the
most part, to small religious sects in this country and to primitive cultures elsewhere. Members
of organized religions in most parts of the world look to psychology and medical science for help
with major psychological disorders; in fact, the Roman Catholic Church requires that all healthcare resources be exhausted before spiritual solutions such as exorcism can be considered.
Nonetheless, miraculous cures are sometimes achieved by exorcism, magic potions and rituals,
and other methods that seem to have little connection with modern science. It is fascinating to
explore them when they do occur, and we return to this topic in subsequent chapters. But such
cases are relatively rare, and almost no one would advocate supernatural treatment for severe
psychological disorders except, perhaps, as a last resort.
The Biological Tradition
Physical causes of mental disorders have been sought since early in history. Important to the
biological tradition are a man, Hippocrates; a disease, syphilis; and the early consequences of
believing that psychological disorders are biologically caused.
Hippocrates and Galen
The Greek physician Hippocrates (460–377) is considered to be the father of modern Western
medicine. He and his associates left a body of work called the Hippocratic Corpus, written
between 450 and 350 (Maher & Maher, 1985a), in which they suggested that psychological
disorders could be treated like any other disease. They did not limit their search for the causes of
psychopathology to the general area of “disease,” because they believed that psychological
disorders might also be caused by brain pathology or head trauma and could be influenced by
heredity (genetics). These are remarkably astute deductions for the time, and they have been
supported in recent years. Hippocrates considered the brain to be the seat of wisdom,
consciousness, intelligence, and emotion. Therefore, disorders involving these functions would
logically be located in the brain. Hippocrates also recognized the importance of psychological
and interpersonal contributions to psychopathology, such as the sometimes-negative effects of
family stress; on some occasions, he removed patients from their families.
Emotions are contagious and can escalate into mass hysteria.
The Roman physician Galen (approximately 129–198) later adopted the ideas of Hippocrates and
his associates and developed them further, creating a powerful and influential school of thought
within the biological tradition that extended well into the 19th century. One of the more
interesting and influential legacies of the Hippocratic-Galenic approach is the humoral theory of
disorders. Hippocrates assumed that normal brain functioning was related to four bodily fluids
or humors: blood, black bile, yellow bile, and phlegm. Blood came from the heart, black bile
from the spleen, phlegm from the brain, and choler or yellow bile from the liver. Physicians
believed that disease resulted from too much or too little of one of the humors; for example, too
much black bile was thought to cause melancholia (depression). In fact, the
term melancholer, which means “black bile,” is still used today in its derivative
form melancholy to refer to aspects of depression. The humoral theory was, perhaps, the first
example of associating psychological disorders with a “chemical imbalance,” an approach that is
widespread today.
The four humors were related to the Greeks’ conception of the four basic qualities: heat, dryness,
moisture, and cold. Each humor was associated with one of these qualities. Terms derived from
the four humors are still sometimes applied to personality traits. For example, sanguine (literal
meaning “red, like blood”) describes someone who is ruddy in complexion, presumably from
copious blood flowing through the body, and cheerful and optimistic, although insomnia and
delirium were thought to be caused by excessive blood in the brain. Melancholic means
depressive (depression was thought to be caused by black bile flooding the brain).
A phlegmatic personality (from the humor phlegm) indicates apathy and sluggishness but can
also mean being calm under stress. A choleric person (from yellow bile or choler) is hot
tempered (Maher & Maher, 1985a).
Excesses of one or more humors were treated by regulating the environment to increase or
decrease heat, dryness, moisture, or cold, depending on which humor was out of balance. One
reason King Charles VI’s physician moved him to the less stressful countryside was to restore
the balance in his humors (Kemp, 1990). In addition to rest, good nutrition, and exercise, two
treatments were developed. In one, bleeding or bloodletting, a carefully measured amount of
blood was removed from the body, often with leeches. The other was to induce vomiting; indeed,
in a well-known treatise on depression published in 1621, Anatomy of Melancholy, Robert
Burton recommended eating tobacco and a half-boiled cabbage to induce vomiting (Burton,
1621/ 1977). If Judy had lived 300 years ago, she might have been diagnosed with an illness, a
brain disorder, or some other physical problem, perhaps related to excessive humors, and been
given the proper medical treatments of the day: bed rest, a healthful diet, exercise, and other
ministrations as indicated.
In ancient China and throughout Asia, a similar idea existed. But rather than “humors,” the
Chinese focused on the movement of air or “wind” throughout the body. Unexplained mental
disorders were caused by blockages of wind or the presence of cold, dark wind (yin) as opposed
to warm, life-sustaining wind (yang). Treatment involved restoring proper flow of wind through
various methods, including acupuncture.
Bloodletting, the extraction of blood from patients, was intended to restore the balance of humors
in the body.
Hippocrates also coined the word hysteria to describe a concept he learned about from the
Egyptians, who had identified what we now call the somatic symptom disorders. In these
disorders, the physical symptoms appear to be the result of a medical problem for which no
physical cause can be found, such as paralysis and some kinds of blindness. Because these
disorders occurred primarily in women, the Egyptians (and Hippocrates) mistakenly assumed
that they were restricted to women. They also presumed a cause: The empty uterus wandered to
various parts of the body in search of conception (the Greek word for “uterus” is hysteron).
Numerous physical symptoms reflected the location of the wandering uterus. The prescribed cure
might be marriage or, occasionally, fumigation of the vagina to lure the uterus back to its natural
location (Alexander & Selesnick, 1966). Knowledge of physiology eventually disproved the
wandering uterus theory; however, the tendency to stigmatize dramatic women as hysterical
continued unabated well into the 1970s, when mental health professionals became sensitive to
the prejudicial stereotype the term implied. As you will learn in Chapter 6, somatic symptom
disorders (and the traits associated with them) are not limited to one sex or the other.
The 19th Century
The biological tradition waxed and waned during the centuries after Hippocrates and Galen but
was reinvigorated in the 19th century because of two factors: the discovery of the nature and
cause of syphilis and strong support from the well-respected American psychiatrist John P. Grey.
Syphilis
Behavioral and cognitive symptoms of what we now know as advanced syphilis, a sexually
transmitted disease caused by a bacterial microorganism entering the brain, include believing
that everyone is plotting against you (delusion of persecution) or that you are God (delusion of
grandeur), as well as other bizarre behaviors. Although these symptoms are similar to those
of psychosis—psychological disorders characterized in part by beliefs that are not based in
reality (delusions), perceptions that are not based in reality (hallucinations), or both—researchers
recognized that a subgroup of apparently psychotic patients deteriorated steadily, becoming
paralyzed and dying within 5 years of onset. This course of events contrasted with that of most
psychotic patients, who remained fairly stable. In 1825, the condition was designated a
disease, general paresis, because it had consistent symptoms (presentation) and a consistent
course that resulted in death. The relationship between general paresis and syphilis was only
gradually established. Louis Pasteur’s germ theory of disease, developed in about 1870,
facilitated the identification of the specific bacterial microorganism that caused syphilis.
Of equal importance was the discovery of a cure for general paresis. Physicians observed a
surprising recovery in patients with general paresis who had contracted malaria, so they
deliberately injected other patients with blood from a soldier who was ill with malaria. Many
recovered because the high fever “burned out” the syphilis bacteria. Obviously, this type of
experiment would not be ethically possible today. Ultimately, clinical investigators discovered
that penicillin cures syphilis, but with the malaria cure, “madness” and associated behavioral and
cognitive symptoms for the first time were traced directly to a curable infection. Many mental
health professionals then assumed that comparable causes and cures might be discovered for all
psychological disorders.
John P. Grey
The champion of the biological tradition in the United States was the most influential American
psychiatrist of the time, John P. Grey (Bockoven, 1963). In 1854, Grey was appointed
superintendent of the Utica State Hospital in New York, the largest in the country. He also
became editor of the American Journal of Insanity, the precursor of the current American
Journal of Psychiatry, the flagship publication of the American Psychiatric Association (APA).
Grey’s position was that the causes of insanity were always physical. Therefore, the mentally ill
patient should be treated as physically ill. The emphasis was again on rest, diet, and proper room
temperature and ventilation, approaches used for centuries by previous therapists in the
biological tradition. Grey even invented the rotary fan to ventilate his large hospital.
Under Grey’s leadership, the conditions in hospitals greatly improved and they became more
humane, livable institutions. But in subsequent years they also became so large and impersonal
that individual attention was not possible.
In the 19th century, psychological disorders were attributed to mental or emotional stress, so
patients were often treated sympathetically in a restful and hygienic environment.
In fact, leaders in psychiatry at the end of the 19th century were alarmed at the increasing size
and impersonality of mental hospitals and recommended that they be downsized. It was almost
100 years before the community mental health movement was successful in reducing the
population of mental hospitals with the controversial policy of deinstitutionalization, in which
patients were released into their communities. Unfortunately, this practice has as many negative
consequences as positive ones, including a large increase in the number of chronically disabled
patients homeless on the streets of our cities.
The Development of Biological Treatments
On the positive side, renewed interest in the biological origin of psychological disorders led,
ultimately, to greatly increased understanding of biological contributions to psychopathology and
to the development of new treatments. In the 1930s, the physical interventions of electric shock
and brain surgery were often used. Their effects, and the effects of new drugs, were discovered
quite by accident. For example, insulin was occasionally given to stimulate appetite in psychotic
patients who were not eating, but it also seemed to calm them down. In 1927, a Viennese
physician, Manfred Sakel, began using increasingly higher dosages until, finally, patients
convulsed and became temporarily comatose (Sakel, 1958). Some actually recovered their
mental health, much to the surprise of everybody, and their recovery was attributed to the
convulsions. The procedure became known as insulin shock therapy, but it was abandoned
because it was too dangerous, often resulting in prolonged coma or even death. Other methods of
producing convulsions had to be found.
Benjamin Franklin made numerous discoveries during his life with which we are familiar, but
most people don’t know that he discovered accidentally, and then confirmed experimentally in
the 1750s, that a mild and modest electric shock to the head produced a brief convulsion and
memory loss (amnesia) but otherwise did little harm. A Dutch physician who was a friend and
colleague of Franklin tried it on himself and discovered that the shock also made him “strangely
elated” and wondered if it might be a useful treatment for depression (Finger & Zaromb, 2006, p.
245).
Independently in the 1920s, Hungarian psychiatrist Joseph von Meduna observed that
schizophrenia was rarely found in individuals with epilepsy (which ultimately did not prove to be
true). Some of his followers concluded that induced brain seizures might cure schizophrenia.
Following suggestions on the possible benefits of applying electric shock directly to the brain—
notably, by two Italian physicians, Ugo Cerletti and Lucio Bini, in 1938—a surgeon in London
treated a depressed patient by sending six small shocks directly through his brain, producing
convulsions (Hunt, 1980). The patient recovered. Although greatly modified, shock treatment is
still with us today. The controversial modern uses of electroconvulsive therapy are described in
Chapter 7. It is interesting that even now we have little knowledge of how it works.
During the 1950s, the first effective drugs for severe psychotic disorders were developed in a
systematic way. Before that time, a number of medicinal substances, including opium (derived
from poppies), had been used as sedatives, along with countless herbs and folk remedies
(Alexander & Selesnick, 1966). With the discovery of Rauwolfia serpentine (later
renamed reserpine) and another class of drugs called neuroleptics (major tranquilizers), for the
first time hallucinatory and delusional thought processes could be diminished in some patients;
these drugs also controlled agitation and aggressiveness. Other discoveries
included benzodiazepines (minor tranquilizers), which seemed to reduce anxiety. By the 1970s,
the benzodiazepines (known by such brand names as Valium and Librium) were among the most
widely prescribed drugs in the world. As drawbacks and side effects of tranquilizers became
apparent, along with their limited effectiveness, prescriptions decreased somewhat (we discuss
the benzodiazepines in more detail in Chapters 5 and Chapters 11).
Throughout the centuries, as Alexander and Selesnick point out, “The general pattern of drug
therapy for mental illness has been one of initial enthusiasm followed by disappointment” (1966,
p. 287). For example, bromides, a class of sedating drugs, were used at the end of the 19th
century and beginning of the 20th century to treat anxiety and other psychological disorders. By
the 1920s, they were reported as being effective for many serious psychological and emotional
symptoms. By 1928, one of every five prescriptions in the United States was for bromides. When
their side effects, including various undesirable physical symptoms, became widely known, and
experience began to show that their overall effectiveness was relatively modest, bromides largely
disappeared from the scene.
Neuroleptics have also been used less as attention has focused on their many side effects, such as
chronic tremors and shaking. However, the positive effects of these drugs on some patients’
psychotic symptoms of hallucinations, delusions, and agitation revitalized both the search for
biological contributions to psychological disorders and the search for new and more powerful
drugs, a search that has paid many dividends, as documented in later chapters.
Consequences of the Biological Tradition
In the late 19th century, Grey and his colleagues ironically reduced or eliminated interest in
treating mental patients, because they thought that mental disorders were the result of some asyet-undiscovered brain pathology and were therefore incurable. The only available course of
action was to hospitalize these patients. Around the turn of the century, some nurses documented
clinical success in treating mental patients but were prevented from treating others for fear of
raising hopes of a cure among family members. In place of treatment, interest centered on
diagnosis, legal questions concerning the responsibility of patients for their actions during
periods of insanity, and the study of brain pathology itself.
Emil Kraepelin (1856–1926) was the dominant figure during this period and one of the founding
fathers of modern psychiatry. He was extremely influential in advocating the major ideas of the
biological tradition, but he was little involved in treatment. His lasting contribution was in the
area of diagnosis and classification, which we discuss in detail in Chapter 3. Kraepelin (1913)
was one of the first to distinguish among various psychological disorders, seeing that each may
have a different age of onset and time course, with somewhat different clusters of presenting
symptoms, and probably a different cause. Many of his descriptions of schizophrenic disorders
are still useful today.
By the end of the 1800s, a scientific approach to psychological disorders and their classification
had begun with the search for biological causes. Furthermore, treatment was based on humane
principles. There were many drawbacks, however, the most unfortunate being that active
intervention and treatment were all but eliminated in some settings, despite the availability of
some effective approaches. It is to these that we now turn.
The earliest explanations for psychological
disorders were based on religious and
supernatural beliefs. For example, many
believed that abnormal behavior was due to
possession by demons or evil spirits.
Hippocrates was one of the first to consider the
role of biology in causing psychological
disorders.
Alison is expressing a supernatural view because evil spirits refers to something outside or
beyond the natural world. Common treatments adopted by those who believe in supernatural
explanations for abnormal behavior include exorcism and prayer.
All of these individuals are known for their work to reform asylums by providing more humane
and therapeutic treatment of patients. Before the reform efforts of individuals such as these, the
earliest asylums functioned more as prisons than hospitals or treatment centers.
Albert is expressing a humoral view because bloodletting and induced vomiting were treatments
used to attempt to bring the four humors back in balance. This view originated with Hippocrates
and the ancient Greeks and is perhaps the first example of associating psychological disorders
with a chemical imbalance in the body.